Skip to main content

Full text of "The clinique médicale; or, Reports of medical cases"

r 



THE 

CLINIQUE MEDICALE; 

OR 

REPORTS OF MEDICAL CASES : 
By g. andral, 

PROFESSOR TO THE FACULTY OF MED1CINE OF PARIS, MEMBER OF THE ROYAL ACADEMY OF MEDICINE, 

&C. &C. 

CONDENSED AND TRANSLATED, 

WITH OBSERVATIONS EXTRACTED FROM THE WRITINGS OF THE MOST 
DISTINGU1SHED MEDICAL AUTHORS : 



By D. SPILLAN, M.D. 



FELLOW OF THE KING AND QUEEN S COLLEGE OF PHYSICIANS IN IRELAND, MEMBER OF THE ASSOCIATION OF 
THE FELLOWS AND LICENTIATES OF THE COLLEGE OF PHYSICIANS, AND FORMERLY 
PHYSICUN TO THE DUBLIN GENERAL DISPENSARY. 



Nulla est alia pro certo noscendi via, nisi quâm plurimas et morborum et dissectionum historias, tum 
aliorum, tum proprias, collectas habere, et inter se comparare. 

Morgagni, de Sedib. et Caus. Morb,, lib. iv., proem. 



LONDON: 

HENRY RENSHAW, MEDICAL BOOKSELLER AND PUBLISHER, 

356, STRAND. 



MDCCCXXXVI. 




LONDON : 
BRADBURY AND EVANS, PRINTERS, 
WHITEFRIâRS. 



G. ANDRAL, 



FACULT VTIS MEDICJNiE PARISIENSIS PROFESSORI, 

LEGIONIS HONORIS EQUITI, 

&c. &c. &c. &c. &c. 

SUMMUM SUMMO OMNIUM CONSENSU LOCUM 
INTER PATHOLOGOS 
HUJUSCE S^CULI SORTITO, QUIPPE CUr ARS MEDENDI TANTUM REFERT 
ACCEPTUM QUANTUM INTER VIVOS NEMINI 
HANC CELEBERRIMI EJUS OPERIS 
IN LINQUAM ANGLICAM VERSIONEM DEDICAT 

D. SPILLAN. 



Londini, 
Kaknd. Oct. 1836. 



INTRODUCTION. 

BY THE TRANSLATOR. 



The importance of the study of clinical medicine is now so universally 
acknowledged, that it appears aitogether unnecessary to occupy the reader's 
time or attention by pointing out to him its various and manifoîd 
advantages. 

This study may be considered as the complément of Médical Education, 
it being neither more nor less than the application of ail other branches of 
the healing art to that which is their ultimate end and aim, namely, the 
prévention, alleviation, and cure of diseases. In order thoroughly to 
understand a disease, it is absolutely necessary to have seen it, to have 
carefully watched it, and traced it through its différent stages during life, 
and to note the vestiges which it may have left behind after death. After 
this method of studying disease, which we hold to be absolutely indispens- 
able, accurate descriptions of disease coming from men on whose judgment, 
attainments, and expérience reliance may be placed, hold the next rank : 
good descriptions of disease teach us the art of observing for ourselves, 
they correct our errors, and direct our attention to objects which might 
otherwise have escaped us. Thèse descriptions, when consulted after we 
have devoted ourselves for some time to clinical observation, engrave the 
phenomena which we have witnessed more deeply in our memory. Again, 
however, we would impress it on the student's mind they never can be 
substituted for the actual observation of disease at the bed-side. In order 
to become sound physicians, nature herself must be interrogated— that is 
the book which must be attentively perused. 

For the purpose of assisting more particularly the junior student in his 
clinical studies, we shall offer a few observations, principally in référence 
to the important subject of diagnosis, the method of examining a patient, 
and the more striking phenomena of semeiology. 

By Diagnosis is understood the knowledge of those characters which 
serve to distinguish diseases from one another. The exact appréciation of 
the several organic altérations, of the symptoms, and of the local and 
gênerai signs to which thèse altérations give rise, chiefly constitutes 



INTRODUCTION. 



diagnosis. This, whilst it is one of the most important branches of 
pathology, and without doubt one of the most difficulté is also the only 
basis on which we can found a just prognosis and rational treatment. 

To assist in forming the diagnosis, several methods are occasionally em- 
ployed. The first, and certainly the most simple, consists in directly 
referring the symptoms observed to the lésion of that organ or tissue 
which those symptoms seem to point out as the seat of sufTering. Thus, 
when a patient présents himself with difficulty of breathing, cough, deep- 
seated pain, dulness of sound, and crepitous râle on one side of the chest, 
sputa streaked with blood, etc., we at once pronounce the lung to be the 
seat of the disease. If the patient should die, the post mortem examina- 
tion confirais this part of the diagnosis, and complètes it by disclosing the 
nature of the lésion. If the patient survive, as identical symptoms 
carinot dépend on différent lésions, and post mortem examination has 
shown, under similar circumstances, that the above mentioned symptoms 
invariably accompany such a lésion of the lung, the diagnosis still has ail 
the certainty that can be desired. 

Another method applies to cases in which the symptoms being slight are 
not easily interpreted ; when the différences are not easily appreciated 
between those which arise directly from the organ affected, and those 
which are merely sympathetic ; this includes the greater number of chronic 
diseases. This method consists in interrogating ail the organs one after 
another, until we corne to that which accounts sufficiently for ail the 
symptoms observed. Here we commence by a rapid examination of 
the parts contained in the head, chest, and abdomen ; and in this first 
review we exclude ail those organs and tissues of whose healthy condition 
we entertain no doubt, and we note ail those which we at ail suspect to be 
the seat of any lésion. This first process being concluded, we proceed to 
a second examination, which is directed solely to the tissues or organs 
suspected. We then make a new sélection among thèse, or, more properly 
speaking, we again exclude ; this exclusion affects those whose suffering 
is evidently merely sympathetic, still reserving those of which we have 
any doubt for a still stricter examination. Lastly, in a third process we 
remove successively ail those tissues, the lésion of which does not account 
sufficiently for ail the symptoms observed, and thus we corne to the real seat 
of the disease ; should there be any difficulty then in deciding between 
two organs, it is more than probable that there is a simultaneous lésion 
of bot h. 

In the practice of Medicine a correct diagnosis necessarily leads to a 
rational treatment — in order to form such a diagnosis, it is necessary to 
know the organs and functions in their normal state ; without this know- 
ledge we cannot appreciate the changes induced by disease. Anatomy 
and Physiology are, therefore, preliminary and indispensable. 



INTRODUCTION. 



VU 



Bv the symptom of a disease is meant an altération of some parts of the 
body, or of some of its fonctions, produced by a morbific cause, and per- 
ceptible to the sensés. From the altération of the function we infer an 
altération in the organ to which the discharge of such function was con- 
fided. When we have ascertained what organ is the seat of lésion, and 
what the nature of the lésion is, the symptom is converted into a sign. 
The sensés alone are sufficient to make us perceive the symptoms; persons 
wholly unacquainted with medicine may ascertain them. There is no one, 
for instance, who cannot perceive what a pain of the side is, with dyspnœa, 
haemoptysis, &c. ; it is only the physician who can tell what thèse symp- 
toms signify ; i. e. can convert them into signs. 

The study of mere symptoms, without endeavouring to ascertain the 
signification of thèse symptoms, has been at ail times productive of much 
mischief in the treatment of disease. Not long since, médical men, 
destitute of the light of pathological anatomy, considered mere groups 
of symptoms as diseases, against which they directed their therapeutic 
agents. This method, evenat the présent time, finds many staunch abettors. 
To illustrate the absurdity of this method, we shall suppose a case of 
paralysis. A little time ago it was not known, and several seem not yet 
to know, that paralysis is but a symptom of an altération in the brain or its 
appendages. Pathological anatomy has proved this point beyond ail 
doubt. Well ! what was the practice adopted in paralysis ? Frictions 
and rubefacients were employed to restore sensation to the paralysed limb. 
So far, if no good was done^ no injury resulted from the practice. But 
some one took it into his head to give nux vomica to an animal ; the hind 
parts of the animal were observed to be convulsed after the employment 
of this drug ; it was thence inferred that the medicine would perform won- 
ders in paraplegia, It was afterwards given in cases of hemiplegia, and was 
observed to produce convulsions in the paralysed limbs, and forthwith it 
was expected that it would restore motion to thèse limbs. Had physicians 
known that paralysis was but a symptom of an acute or chronic local affec- 
tion of the brain, they would have seen that the means proposed to give 
motion to the paralysed limbs, must necessarily act on the diseased portion 
of the encephalon ; and in thus causing the diseased part to act, they 
rather prevented than promoted its cure. They would have seen, that to 
make the limbs perform motion in this case, was just the same as rubbing 
the two ends of a fractured bone one against the other, by way of con- 
solidating the fracture. Numerous other instances might be adduced of 
the absurdity and mischief resulting from confining attention exclusively 
to the symptoms. 



vin 



INTRODUCTION. 



MODE OF INTERROGATING A PATIENT. 

Nothing is more embarrassing to a young and inexperienced physician 
than the office of examining a patient. It is beyond ail doubt one of the 
most important parts of his profession, one vvithout which he cannot attain 
a sure diagnosis, and consequently cannot adopt a rational mode of treat- 
ment, This is, however, a brancli too much neglected in the éducation of 
médical men. There is often great incohérence and confusion observable 
in their questions. Thèse questions are frequently totally mal-apropos, 
and devoid of ail connection ; such persons oftentimes confound objects 
the most dissimilar, and keep separate those that bear the strongest 
resemblances. Thèse disadvantages arise from a want of order and 
method. The mode of taking a case, as it is closely connected with that 
of examining a patient, participâtes in ail the above defects in the hands 
of the inexperienced. 

The first thing that should be done is, to examine the exterior — the 
physiognomy first should engage our attention ; by this we obtain some idea 
of the patient's âge and strength, state of his mind, circumstances of 
prime importance in establishing our prognosis and mode of treatment. 
This first examination should not be confined to the head ; the physician 
should extend his examination to ail the régions of the body, in order that 
he may be able to judge of the form of the body, its size, colour, érup- 
tions, if there should be any. Such examination should be made, where it 
ean be done with convenience. The necessity of minutely examining the 
exterior of the body, more particularly in the part which may be the 
seat of pain, has been very well pointed out by M. Rostan, in the fol- 
lowing case : — An aged woman was admitted into the hospital under his 
care : she complained of an acute pain in the abdomen, towards the left 
iliac fossà, Face flushed, skin hot, puise strong and fréquent ; tongue 
dry, considérable thirst ; digestive functions natural, little or no change 
in the other organic or animal functions. The abdominal pain was very 
sensible on pressure, and when she moved. His diagnosis was as follows : 
the phenomena of reaction, (strength and frequency of puise, flushed 
face, thirst, &c.) indicated an acute state, and one, no doubt, of aninflam- 
matory character. The local sign showed, that the abdomen was the seat 
of the disease ; but the digestive functions were natural, so that it was not 
in the digestive organs that the inflammation was seated. The slightest 
pressure gave pain, which showed that the disease was superficial. Motion 
was painful, the organ of motion was therefore aflected ; the abdominal 
muscles therefore must be the seat of disease. After forming this diagnosis, 
he prescribed for the patient accordingly, and then left her, when one 
of the pupils who had raised the patient's chemise for the purpose of 



INTRODUCTION. 



IX 



examining the seat of pain, followed him, and informed him that it was a 
case of zona. This lesson made us feel more than ever says, M. Rostan, the 
necessity of using our sensés, the only means of positive instruction. Another 
case is mentioned by the same author in proof of the same theory. A patient 
had fallen on a pointed body, and felt considérable pain in the left side of the 
chest ; there was cough, accompanied with great pain ; some expectoration, 
sputa streaked with blood, and symptoms of well-marked reaction. The 
pain was very acute to the touch. One of the pupils examined the 
patient, and formed his diagnosis thus : the cough and spitting of blood 
prove that the respiratory organs, and probably the lungs, must be the seat 
the disease. The very acute ain of the side, which was increased both 
by pressure and by respiration, might be, to be sure in the thoracic pari- 
etes ; but the strength and frequency of the puise, the redness of the 
face, the heat of skin, thirst, &c. indicated a more deep-seated lésion* 
(percussion could not be employed on account of the acuteness of the 
pain ; a crepitous râle was detected by the stéthoscope). The pupil's dia- 
gnosis was pleur o-pneumonia. This certainly was reasoning from very 
correct principles ; but what was the real state of the patient ? There 
was a fracture of the ribs. Had the state of the exterior been examined, 
this error would have been avoided. 

The first question to be addressed to a patient should be— " Where 
have you any pain ? " This question, simple as it may appear, is far 
the best. Patients are very much disposed to give an opinion on the 
nature of their own case. One will tell you that it is his nerves that are 
afFected ; another, that he is troubled with the bile. If, instead of putting 
the question as is above recommended, the physician were to ask the 
patient — " What ails you ?" he may be sure to receive an answer that 
will leave him as much in the dark with respect to the nature of the 
patient 's disease as he was before he put the question ; whereas, by asking 
him where his ailment lies, the patient seldom fails to point out the 
function and organ diseased. Even with this précision in conducting our 
examination, it is oftentimes difficult to prevent patients from wandering 
into rigmarole accounts concerning their complaints ; frequently, too, they 
take one organ for another ; they ? for instance, complain of a pain in the 
stomach, when the seat of disease is in the chest. It is useful, in order to 
avoid ail misunderstanding, to bid them lay their hand on the part where 
they feel pain. The next question should be — " How long are you ailing 
in this way ? " By this you ascertain whether the disease be acute or 
chronic. If we discover that the disease is of récent occurrence, we then 
confine our attention solely to the considération of acute diseases, excluding 
altogether chronic diseases of the same organ. We shall take an example 
for the sake of illustration. The acute diseases of the brain are:— con- 
gestion, inflammation of the membranes, that of the cérébral substance^ 



X 



INTRODUCTION. 



hemorrhage, ramollissement. The chronic diseases are : — tubercles, cancer, 
aceplialocysts, osseous tumours of the parietes of the cranium, fungus of 
the dura mater, gênerai affections of this organ, such as hysteria, epilepsy. 
&e. &c. Well, if the disease is only of a few days' standing, we shail 
conclude that it is acute, and shall lay aside ail those now enumerated in 
the chronic list ; we shall then confine our attention to congestion, menin- 
gitis, encephalitis, apoplexy, &c, the diagnostic signs of which we shall 
soon ascertain. 

Now, when we know what the function is that has been injured, we 
must follow up its examination, until we have passed in review ail the 
morbid phenomena which it may présent. When this examination is com- 
pleted, we pass on to the function or organ which exercises the most marked 
influence over that which has been just examined, or which receives 
the most marked influence from it. We then pass in review, one after 
another, ail the principal organs and their gênerai functions. Whenever 
an organ is seriously affected, it reacts on the other organs, disturbs their 
functions, and sometimes their structure. How are we to discover thèse 
consécutive altérations, unless by examining ail the organs and ail their 
functions ? 

When we have examined the patient in the manner now described, we 
next endeavour to ascertain the state of the différent organs contained in 
the thoracic and abdominal cavities, by means of percussion and ausculta- 
tion. For a description of the mode of practising thèse instruments of 
clinical investigation, we must refer to the works expressly written on 
thèse subjects. 

There are several circumstances which may prevent the physician from 
examining his patient in the manner now described. He will then be 
obliged to have recourse to the statements of those in attendance on the 
patient ; he must make use of his own sensés ; the sensé of sight will make 
known to him ail the phenomena regarding the external appearance of the 
patient ; by touch he can discover the température, consistence, and 
sensibility of most of the superficial and deep-seated parts, the state of 
the circulation, &c ; by his ear he can ascertain ail the various sounds 
produced by percussion, or discoverable by the stéthoscope. We shall cite 
an example, to show that the dihiculty of ascertaining the seat and nature 
of a disease, even in cases wherein serious obstacles may présent them- 
selves, is not so great as may appear at first sight. Let us suppose an 
example : — • 

A patient is presented to us in a state of complète loss of consciousness. 
It is altogether impossible to obtain from him any information with re- 
spect to his présent feelings, or the previous history of the case. We 
merely learn from his friends, and those around him, that, up lo the 
period of his illness. he was in the enjoyment of perfect health, and that 



INTRODUCTION. 



the présent attack was sudden. Having no other sources of information 
as to the nature of the case, we call in our sensés and reason to our aid. 
The former tell us that the patient may be about sixty years of âge ; that 
he is of a strong make ; that the several cavities are large, and his limbs 
well developed ; that his face is flushed ; that the eyes are prominent, 
and that the temporal and carotid arteries beat with violence ; that 
he is frothing at the mouth ; that the extremities are cold ; that one side 
of the body is deprîved of motion ; that the puise is strong and hard ; that 
he has vomited, and that he has passed his fseces involuntarily ; that the 
breathing is stertorous. What is to be done in this case ? Do we not see, 
in a moment, what the disease is, its nature, seat, extent, and the indica- 
tions of treatment ? Let us now reason on the case. There is complète 
loss of consciousness. What are the diseases which gave rise to this 
symptom ? Diseases of the heart, of the lung, and of the brain. Is the 
heart the seat of the disease at présent ? No ; for the patient was very 
well before the présent attack, and the circulation was not disturbed. Is 
it syncope ? No ; for the face is flushed, and the puise is strong and full. 
Is it asphyxia ? No ; for the respiration and circulation still exist, and 
there was no asphyxiating cause. The brain, therefore, must be the organ 
involved. We have now placed the disease in the brain, but the diseases 
of this organ are numerous. The disease is evidently not chronic, for the 
patient was very well a little before the attack. Thus, then, by this single 
trait, we have got rid of one half the cérébral affections. We now have left 
for considération arachnitis, cérébral congestion, softening, and hemor- 
rhage 3 it cannot be congestion, for congestion is a gênerai disease, and here 
there are local phenomena : nor can it be arachnitis, for the same reason. 
It must, therefore, be either softening or effusion ; but the progress of soft- 
ening, which also produces hemiplegia is slow and graduai, and here the 
disease cornes on suddenly. The case, therefore, must be one of a cérébral 
hemorrhage, or apoplexy. Thus, then, have we corne, by the mere ap- 
plication of the sensés, and by reasoning, to ascertain the nature, seat, and 
extent of the disease which we have before our eyes, and that with almost 
mathematical certainty. 

After examining the patient in this way, it next remains for us to go 
back to the previous circumstances which might have acted as causes, 
or which might furnish some useful data for the treatment. We should 
inquire to what cause the patient attributes his disease ; whether the 
disease be hereditary or acquired ; whether the présent is the first attack 
of it, or whether it appeared on a former occasion. Lastly, we should 
direct attention to the âge, sex, constitution, idiosyncrasy, habits, and 
profession of the patient. 

When the disease terminâtes fatally, the task of the clinical observer 
is not yet finished. This is the moment when nature will either confirai 



Xll 



INTRODUCTION. 



the accuracy of his diagnosis, or prove its incorrectness. The autopsy 
requires the same attention from the physician as the examination of the 
patient did before death. 

As the same method of examination may not always apply in ail cases, 
\ve shall, for the benefit of the junior student, annex the plan of examina- 
tion recommended by M. Louis ; it is as follows : 

Before the clinical student inquires into the symptoms in any case, 
he should inquire into the âge and profession of the patient ; into his 
usual state of embonpoint or emaciation, of strength or weakness, of 
health or disease ; of the affections under which he laboured before the 
présent ; of the natural conformation of his body. 

The reasons for thèse inquiries are obvious. 

When thèse points are ascertained, we should next proceed to ascertain 
the period when the disease commenced ; as, without knowing this, we 
could not learn with certainty its progress and duration, nor should we 
have ail the éléments of the prognosis and treatment. It should be 
ascertained whether, before the time at which the patient states his 
disease commenced, he was in perfect health, whether ail the functions 
were duly performed: a strict inquiry into this particular is indispensable 
among persons in the humbler walks of life, since they generally date the 
commencement of their disease from the time at which they were forced to 
give up their ordinary occupations. By way of illustrating the necessity 
of this inquiry, let us suppose a case of pleuritis, the first symptoms of which 
commenced only a few days before the patient came under the examina- 
tion of the physician ; let us suppose that the patient states that he was 
in perfect health before this pleuritic attack ; here the prognosis will of 
course be favourable, as expérience shows us that pleuritis, attacking a 
person previously in good health, almost always terminâtes well. But, if 
we ascertain by our inquiries that the patient, long before the pleuritic 
attack, was harassed with a cough; if we find, moreover, that this 
cough is connected with tubercles in the lungs, the prognosis and treat- 
ment will be seriously modified. 

Having ascertained the time when the disease commenced, we then 
corne to the considération of the symptoms. Thèse should be studied 
one by one in the exact order in which they appeared from the commence- 
ment of the disease to the period when the patient cornes under our 
examination. 

Paihological Anatomy should now be brought in to assist the other 
methods of examination. The use of pathological anatomy is not only to 
discover the seat of diseases, to deveîop their nature, and unravel their 
complications ; by it also we arrive at a knowledge of many of the laws 
observed by disease, knowledge which can only be obtained from an at- 
tentive examination of ail the organs, whenever the patient has died of 



INTRODUCTION. 



xiii 



the disease. We now know, for instance, that, after the âge of fifteen, 
whenever we nnd tubercles in any organ, we are sure they also exist at 
the same time in the lungs. It is evidently to pathological anatomy we 
are indebted for our knowledge of this law. 

Having now ascertained the state of the functions, and learned the 
symptoms which have occurred from the commencement of the disease up 
to the period at which the patient came under our inspection, we must 
next endeavour to ascertain the value of those symptoms, we must cou- 
vert thèse symptoms into signs, in order to arrive at the knowledge of the 
organ affected, and of its pathological state. This becomes the more 
necessary, as there are cases in which the symptoms do not, either at the 
commencement of the disease, or during a considérable portion of its 
progress, indicate an appréciable altération of any organ whatever. This 
conversion of symptoms into signs is to be accomplished by carefully 
noting the exact séries and précise connection of thèse symptoms ; the 
method of exclusion, or remotion, also is sometimes to be employed ; that 
is to say, we attain a knowledge of the organ afFeeted, not so much from 
any serious disturbance of its peculiar functions, as because whilst the 
other viscera gave no sign of any appréciable altération, that viscus alone 
should be considered as the seat of the disease whose functions are in any 
way altered, even though such altération may not be very marked. 

Having now ascertained the organ afFeeted, our next object is, to learn 
the nature of the disease, of which it is the seat. The difticulty of 
solving this question is not inconsiderable ; this difficulty is in a great 
measure occasioned by the want of anatomical examinations, carefully 
conducted at différent periods of the same disease. It is chiefly by the 
aid of pathological anatomy, by comparing the symptoms with the lésions 
corresponding to them, that this question can be solved. 

When we have now ascertained the symptoms of the disease, the organ 
which is its seat, the nature of the disease, and its probable duration, the 
prognosis présents itself to our considération. In forming the prognosis 
we must, in addition to the above data, take into considération the degree 
of fever présent, the âge and strength of the patient*. 

* For much valuable information on the subject of Clinical instruction, vre refer the student 
to Dr. Latham's ; ' Lectures on Subjects connectée! with Clinicai Médiane." 



CONTENTS OF PART T. 



FIRST BOOK. 



DISEASES OF THE ENCEPHALIC MEMBRANES. 

PAGE. 



Section I. — Diseases of the Dura Mater . . • • 1 

Section II. — Diseases of the Arachnoid and Pia Mater . . . . 3 

Chap. I. — Cases of Diseases of the Arachnoid and Pia Mater covering 

the upper surface of the Brain ... . .4 

Chap. II. — Diseases of the Méninges of the lower surface of the Brain 16 
Chap. III. — Diseases of the Méninges covering the parietes of the Ven- 

tricles of the Brain . . . . . .18 

Chap, IV. — Cases -wherein the entire of the Méninges were involved . 25 
Chap. V. — Diseases of the Membranes of the Spinal Cord . - . 30 

Recapitulation — Chap. I, Lésions detected in the Méninges by post mortem 
examination. 

Art. 1.— Lésions of the Dura Mater ..... 39 

Art. 2. — Lésions of the Arachnoid . . . . . 40 

Art. 3.— Lésions of the Pia Mater ..... 41 
Chap. II — Disturbances of Function . . . . .45 

Art. i. — Disturbances in the Functions of Relative Life . . ib. 

Section I. — Lésions of Sensibility . . . . . ib. 

Art. 2. — Lésions of Motion . . - ■> . . .50 

Art. 3 — Lésions of Intelligence . . . .56 

Chap. III. — Disturbances of the Functions of the Organs of Nutritive Life. 

Art. 1. — Lésions of the Functions of the Digestive Apparatus . 59 

Art. 2. — Lésions of the Circulation ..... 61 
Art. 3. — Lésions of the Respiration . . . . .63 

Supplément. — Spinal Meningitis ...... «6. 

Symptorns of Meningitis . . . . * 65 



CONTENTS. 



SECOND BOOK. 

DISEASES OF THE BRAIN. PAGE 

First Order — Cérébral Congestions . . . . t',7 

Récapitulation . . . . . 73 

Second Order — Cerebrai Hemorrhage . . . .93 

Récapitulation — Chap. I. Lésions of Motion . . . 107 

Chap. II. Lésions of Sensibility . . . 113 

Chap. III. Lésions of Intelligence . . . 117 

Chap. IV. Lésions of the Functions of the Organs of 

Nutritive Life . . .119 

Supplément — Spinal Congestions . . . 121 

Third Order — Softening of the Cérébral Hemipheres . . 132 

Chap. I Cases where no Symptom announced the Softening . . 133 

Chap. II. — Cases where the Disturbance of Motion was the only symptom 134 
Chap. III. — Cases where, with différent Lésions of Motion, there existed a 

Lésion of Sensibility . . . . 1 44 

Chap. IV. — Cases in which the Loss of Speech was the only symptom, or 

one of the prédominant Symptoms . . . 148 

Chap. V. — Cases in which, with divers Disturbances of Motion and Sensa- 
tion, there was Disturbance of the Intelligence . .149 
Art. 1. — Softening of the Brain, with complète and sudden Loss of Con- 

sciousness . . . . . . ib. 

Art. 2. — Softening of the Brain, with Weakness or Perversion of the In- 
telligence . . . . .154 

Recapitulation . • . . . 159 

Fourth Order — Hypertrophy of the Cérébral Hémisphères . .174 



THIRD BOOK. 



DISEASES OF THE CEREBELI.UM. 



Section I. — Observations on Hemorrhage of the Cerebellum . . 194 

Section IL— Observations on softening of the Cerebellum . 195 



Note. — The translater begs leave to state that the Supplément, which has been condensed 
from Ollivier's work on Diseases of the Spinal Cord, as also ail the Notes — except those at 
pages 44, 60, 85, 94, 165, and 168 — have been added to the présent Translation by himself, he 
feels it necessary to apprise his readers of this circumstance, in conséquence of having negleeted 
to subjoin his signature (T. or Tr.) to the several additions, particularly in the early pages of 
the work. 



CONTENTS OF PART II. 



FIRST BOOK. 



D1SEASES OF THE HEART. 

PAGE 

Section I Observations on Diseases of the Pericardium . .217 

Chap. I Acute Pericarditis . . . . . 218 

Art. I.— Cases of acute Pericarditis with characteristic Symptoms . ib. 

Case 1. — Acute articular Rheuinatism — Suddenly a sharp Pain in the 
Région of the Heart — Speedy Death — Purulent Exudation 
on the internai Surface of the Pericardium . ib 

Case 2. — Pain at the lower Part of the Sternum, and in the Région of 
the Heart, becomïng intense by degrees, succeeding articular 
Pains — Pulsations of the Heart obscure ; Puise strong and 
regular — False Membranes in the Pericardium . . 22u 

Case 3. — Pain in the Région of the Heart, radiating at intervais to the 
left Arm — Beatings of the Heart very strong at the outset, 
but subsequently very obscure ; Puise ail through very small 
and regular — Sound dull in the precordial Région — Great . 
Dyspnœa — Effusion of Blood into the Pericardium . 222 

Case 4. — Symptoms of Pericarditis — Cure . . . 224 

Art. II. — Cases of acute Pericarditis without Pain, but with Dyspnœa . 225 
Case 5 — Pulmonary Tubercles — Breathing very little embarrassed — Ail 
at once great Dyspnœa — Sudden Death — Purulent Effusion 
into the Pericardium . . . ib. 

Case 6. — Slight Asthma for several Years — Ail at once extrême Dyspnœa, 
the constant increase of which caused Death by Asphyxia — 
Serous Effusion into the Pericardium . ib. 

Case 7 — Confluent Small Pox — Complication of Pericarditis, announced 

merely by great Dyspnœa . . . 228 

Art. III Cases of acute Pericarditis without any characteristic Symptom 229 

Case 8. — Symptoms of Meningitis — Acute Inflammation of the Peri- 
cardium . . . . ib. 
Chap. II. — Chronic Pericarditis . . . . 230 
Case 9. — Very thick false Membranes around the Heart — Symptoms of 

Aneurism . . . . ib. 

Case 10. — Very thick false Membranes around the Heart — Dropsy — 
Extrême frequency of Puise — Pericarditis recognised during 
Life .... 232 



ii 



CONTENTS. 



PAGE 

Section II. — Observations on Diseases of the fleshy Substance of the Heart 

and its internai Membrane . . 236 

Chap. I. — Lésions which exist at the onset of Diseases of the Heart — 

Symptoms of thèse Lésions . . . ib. 

Chap. II. — Lésions of Organs, or of Functions, resulting from the Disturb- 
ance which the arterial Circulation undergoes in Cases of 
Disease of the Heart . . . . 246 

Chap. III Lésion of Organs, or of Functions, which resuit from the 

Disturbance which the venous Circulation undergoes in Dis- 
ease of the Heart . . . . . 250 
Art. 1. — Sanguineous Congestions . . . 251 
Art. 2.— Serous Congestions . . . . . 264 
Art. 3. — Lésions of the Heart discovered by Auscultation . . 279 



SECOND BOOK. 



DISEASES OF THE LUNG. 

Section I. — Diseases of the Bronchi . . . 285 

Chap. I. — Organic Altérations of the Bronchi in the state of Inflammation 

— Symptoms of thèse Altérations . . ib. 

Case 1 — Chronic Bronchitis simulating Pulmonary Phthisis — White- 

ness of the Tracheo-Bronchial Mucous Membrane . 287 

Researches regarding the History of the Narrowing and Oblitération of 
the Bronchi . . ... . 289 

Case 2. — Chronic Bronchitis — Narrowing of the principal Bronchus of 
the upper Lobe of the right Lung — Almost entire Absence 
of the Respiratory Murmur in this Lobe . . 291 

Case 3. — Chronic Bronchitis — Thickening of the Parietes of some 
Bronchi, with perceptible narrowing of their Cavity — Pul- 
monary Tubercles on the opposite Side . . . 292 

Case 4. — Chronic Bronchitis — Compression of the large Bronchi of the 
right Lung by a mass of encysted Melanosis — Respiratory 
Murmur weaker on the right Side . . . 293 

Case 5.— -General Chronic Bronchitis — Dilatation of a single Bronchial 
Branch — Absence of characteristic Symptoms of this Dilata- 
tion — Cancer of the Stomach . . . 294 

Case 6 -Chronic Bronchitis, with Aneurism of the Heart — General 

Dilatation of the Bronchi of one Lobe — Peculiar Résonance 

of the Voice . . . . . ib. 

Case 8 — Chronic Bronchitis — Dilatation of several Bronchi — Pecto- 

riloquy . . . . . 295 

Case 9 — Partial Chronic Bronchitis — Dilatation of some Bronchial 
Branches — Mucous Râle in the corresponding Points — Cancer 
of the Liver . . . . .297 

Chap. II. — Altérations in the Sécrétion of the Bronchial Mucous Membrane 299 

Case 10.-— Chronic Bronchitis — Moist Bronchial Râle (Mucous and 
Crepitous Râle blended) over the entire Extent of the two 
Lungs . . . . . ib. 

Case 11. — Chronic Bronchitis — Obstruction of a Bronchus by Mucus — 

Death by Asphyxia . . . .301 



CONTENTS. 

Case 12. — Chronic Broncliitis with Melanosis — Obstruction of Bronchus 

by a mucous Concrétion resembling a Polypus, increasing 

Dyspnœa, and Deatb . 
Case 13. — Chronic Bronchitis — Great Fetor of the Sputa — Melanosis of 

the Lung . . . 

Case 14 Chronic Bronchitis — Abundant Expectoration — Death by 

Marasmus 

Case 15. — Chronic Bronchitis — Abundant Expectoration — Lésion of the 
Pulmonary Parenchyma 

Case 16. — 
Case 17 

Case 18. 

Case 19, 

Case 20. 

Case 21 



— Acute Bronchial Flux producing Death by Asphyxia in an 

Individual affected with Pneumonia and Chronic Bronchitis 
— Serous Flux of the Bronchi, the sudden appearance of which 

coincided with the Absorption of a Hydrothorax . 
— Acute Bronchitis — Measles — Prématuré Disappearance of the 

Eruption ; fatal Dyspnœa 
— Slight Chronic Bronchitis— Suppression of the running of an 

old Ulcer ; fatal Attack of Asthma 
— Old Dyspnœa with Dropsy — Absence of Lésion to account 
for it, either in the Heart or Lungs — Altération of the Dia 
phragmatic and Pneumo-gastric Nerves . 



Section II. — Pleuro -pneumonia ... . 

Chap. I — Pleuro-pneumonia announced by the aggregate of the character 
istic Symptoms .... 
Art. 1. — Pleuro -pneumonias in the first Degree. (Engorgement.) 
Case 1. — 
Case 2.— 

Case 3. — . ■ . 

Case 4. — ........ 

Art. 2. — Pleuro-pneumonias in the second degree. (Red Hepatisation 

Case 5 .... 

Case 6.— . 

Case 7 — .... 
Case 8.— ..... 
Case 9.— 

Case 10 ... 

Case 11.— . 
Case 12.— ..... 
Art. 3. — Pleuro-pneumonias in the third degree 
Case 13. — .... 

Case 14 ..... 

Case 15. — 

Case 16. — ..... 
Chap. II. — Pleuro-pneumonias with the Absence 
characteristic Symptoms 
Art. 1 . — Absence of the Signs furnished by Auscultation and Percussion 
Case 17.— .... 
Case 18.— .... 
Case 19.— . 

Case 20.— .... 
Case 21.— . . 
Case 22.— .... 



(Grey Hepatisation. 



one or more of their 



m 

Page 



302 

305 

306 

307 
308 



IV CONTENTS. 

PAGE 

Art. 2 — Absence of the Signs furnished by Expectoration . 347 

Case 23.— . . . . . . 348 

Case 24 . - . . . .349 

Case 25 . . . . . . 350 

Case 26 . . . . , .351 

Case 27 . . . . . ib. 

Case 28.— • ... 352 

Case 29 . ..... 354 

Case 30.— ..... ib. 

Art. 3. — Simultaneous Absence of tbe Signs furnished by Auscultation, 

Percussion and Expectoration . . . . 355 

Case 31 — ... . . . ib. 

Chap. III. — Pleuro-pneumonias complicated with other Affections . 356 

Case 32 Chronic Broncbitis complicated with Pneumonia . . 357 

Case 33. — Pulmonary Tubercles — Intercurring Pneumonia . . 358 

Case 34. — Pulmonary Tubercles occasioning their softening . . 359 
Case 35. — Pneumonia with Hydrothorax of the opposite Side, and 

Aneurism of the Heart .... 360 
Case 36. — Pneumonia with Pulmonary Œdema and double pleuritic 

Effusion — Intermittent Fever at flrst . . . 361 
Case 37. — Pneumonia with Pericarditis — Fibro-cartilaginous Tumours 

around the Heart ..... 362 

Case 38. — Pneumonia with Hepatitis .... 366 
Case 39. — Pneumonia with gênerai Inflammation of the Gastro -pulmonary 

Mucous Membrane ..... 367 

Case 40. — Double Pneumonia with Enteritis and acute Peritonitis . 369 
Case 41. — Pneumonia at the commencement of Small Pox disappearing 

as the Eruption came out .... 370 

Chap. IV. — Termination of Pneumonia by Gangrené . . . 371 

Case 42 . . . . . ib. 

Case 43.— . . . . . .372 

Case 44.— . . . . . . . . 375 

Chap. V. — Récapitulation, or General History of Pleuro-pneumonia . 377 



CONTENTS OF PART HT. 



DISEASES OF THE CHEST. 

Page 



Section III — Observations on Pulmonary Phthisis . . 413 

Chap. I — Nature and seat of Pulmonary Tubercles . ib. 

Chap. IL — Symptoms of Pulmonary Phthisis . . . 424 

Art. 1. — Symptoms which mark the onset of Pulmonary Phthisis . . ib. 
Art. 2.— Symptoms which accompany Pulmonary Tubercles in the 

différent stages of their existence . . 438 

§ 1. — Signs furnished by Percussion and Auscultation . . . 439 

§ 2. — Signs furnished by the Respiration . . . 448 

§3 Signs afforded by the Cough . . 457 

§4. — Signs afforded by the Expectoration . . . 461 

§ 5. — Signs afforded by Hemoptysis . . . 474 

Chap. III. — Diseases which complicate Pulmonary Tubercles . . 484 
Art. 1. — Diseases which complicate Pulmonary Tubercles, and which are 

seated in the Respiratory Apparatus . . . . 485 

§ 1 — Diseases of the Larynx, Trachea, and Bronchi . . 486 

§ 2. — Diseases of the Pulmonary Parenchyma . . . 497 

§ 3. — Diseases of the Pleura . . . . 502 

§ 4. — Diseases of the Bronchial Ganglions . . . - 506 
Art. 2. — Diseases which complicate Pulmonary Tubercles, and which 

have their seat without the Respiratory Organs . . 511 

§ 1. — Diseases of the Heart and its Appendages . . ib. 

§ 2. — Diseases of the Digestive Tube . . 513 

§ 3. — Diseases of the Organs appended to the Digestive Apparatus . 534 

§ 4. — Diseases of the Urinary Apparatus . . . . 537 

§ 5. — Diseases of the Locomotive Apparatus . . . 538 

§ 6. — Diseases of the Nervous System . . . 540 

§ 7 — Diseases of the Génital Organs . . . 542 

Chap. IV. — Progress and duration of Pulmonary Tubercles . . ib. 

Chap. V — Cicatrisation of Tuberculous Excavations of the Lung . . 54/ 



ii 



CONTENTS. 



Section IV — Observations on différent accidentai productions developed in 

the Lung . .552 



Section V. — Observations on Pleuritis 
Chap. I — Pleurisies without effusion 
Chap. IL— Pleuritis with effusion 

Chap. III. — Partial Pleurisies .... 
Art. 1 — Diaphragmatic Pleurisies 

§ 1 . — Isolated Diaphragmatic Pleurisies 
§ 2 — Diaphragmatic Pleurisies co-existing with Costo-pulmonary 
Pleuritis 
Art. 2. — Interlobular Pleurisies 
Art. 3. — Inflammation of the Médian Pleura 
Art. 4. — Partial Inflammation of the Costo-pulmonary Pleura 

Chap. IV Double Pleurisies with or without effusion 

Chap. V. — Pleurisies complicated with other diseases 
Chap. VI — General history of Pleurisy . . . 



556 
55 J 
559 
571 
572 
ib. 

576 
580 
581 
582 
584 
587 
589 



CONTENTS OF PART IV. 



DISEASES OF THE ABDOMEN. 

PAGE 



Book I. — Diseases of the digestive tube • • • • 609 

Section I. — Observation on fevers ■ • • ib. 

Chap. I Continued fevers terminating in death • • -611 

Art. 1 . — Continued fevers connected witb follicular inflammation of tbe 

intestines • .. • • 612 

§ 1. — Observations on follicular enteritis at the period of tbe exanthème 613 

§ 2. — Observations on follicular enteritis at the period of ulcération • 628 
Art. 2. — Continued fever connected with other forms of gastro-intestinal 

lésion than follicular enteritis • • • 6/3 

Art. 3 — Observations on cases of différent diseases, accompanied with 
typhoid symptoms, without any appréciable lésion of the diges- 

tive tube • . . . . 682 

§ 1 — Typhoid symptoms developed in conséquence of différent lésions 

appréciable by anatomy .... fig3 

§ 2. — Typhoid symptoms without lésions appréciable by anatomy • 698 

Chap. II. — Continued fevers terminating in return to health • -701 

Art. 1. — Treatment by diet and simple diluents • 702 

Art. 2. — Treatment by évacuants .... 706 

Art. 3. — Treatment by antiphlogistics • . 712 

Art. 4. — Treatment by tonics • • . • 717 

Chap. III.— Résumé • • • . 727 

Art. 1 Etiology • • • ib. 

Art. 2 State of the différent organs after death and during life • 729 

Digestive Tube • • • • • ib. 

§ 1. — Lésions found after death in the digestive tube • . ib. 

A. Constancy of the lésions of the digestive tube • ib. 

B. Frequency of the lésions of the digestive tube • • 731 

C. Seat and nature of the lésions of the digestive tube • ib. 

a. Stomach ..... 732 

b. Small intestine • • • • ■ 733 

c. Large intestine . . • • «740 

d. Matters contained in the digestive tube •• ■ • ib. 

D. Connexion between the gastro-intestinal lésions and the symptoms 742 
§ 2.— Functional lésions of the digestive apparatus • • 743 



ii 



CONTENTS. 



ClRCULATORY APPARATUS 

§ 1 — Lésions found after rîeath in the circulatory apparatus 
§ 2. — Lésions of the circulatory apparatus observed during life 
Afparatus of the Lymfhatic Circulation 
Respiratory Apparatus .... 
§ 1. — Lésions of this apparatus observed after death 
§ 2. — Lésions of the respiratory apparatus observed during life 
Apparatus or the Sécrétions ..... 

§ 1 Lésions of the cellular tissue 

§ 2. — Lésions of the serous membranes 

§ 3. — Lésions of the biliary apparatus 

§ 4 — Lésions of the urinary apparatus 

§ 5. — Lésions of the salivary glands and pancréas 

Apparatus of the Life of Relation . ?- . * 

§ 1. — Lésions of those organs observed after death 
§ 2 Lésions of those organs observed during life 

Art. 3. — Treatment • 

§ L — Treatment by diet and mucilaginous or acidulated drinks 

§ 2 Treatment by blood-letting 

§ 3. — Treatment by évacuants 

§ 4. — Treatment by tonics and stimulants 



PAGK 

756 
ib. 
765 

7/0 

771 
ib. 

772 

774 
ib. 

775 
ib. 

778 
ib. 

779 
ib. 
782 

791 
792 
795 
80i 
804 



CONTENTS OF PART V. 



DISEASES OF THE ABDOMEN. 

PAGE 

Sequel of Book I.— Diseases of the digestive tube . - . . 807 
Section II.— Diseases of the digestive tube in which local symptoms alone 

exist, or in which they predominate . . . ib. 

Chap. I — Observations on acute gastritis . . . . ib. 
Chap. II. — Observations on chronic gastritis . . . .818 

Art. 1 — Altérations produced in the stomach by chronic gastritis . . 819 

§ 1. — Altérations of the mucous membrane . . ib. 

§ 2 — Altérations of the tissues subjacent to the mucous membrane . 835 

Art. 2 — Symptoms of chronic gastritis . . . 858 

Art. 3.— .Treatment of chronic gastritis .... 869 

Chap. III. — Observations on some affections of the stomach not inflammatory 870 

Chap. IV. — Observations on lead colic and other affections resembling it . 882 

Art. 1— State of the digestive tube in persons who died with colic . ib. 

Art. 2. — Symptoms of lead colic . . . . 886 

Art. 3 Treatment of lead colic . ... 888 

A. Employment of strychnine .... 890 

B. Employment of brucine . . • 891 
Art. 4 — Nature of lead colic . . . . 892 
Art. 5 Observations on some morbid states, bearing some analogy to 

symptoms &c, of lead colic . . . 893 

Book II. — Diseases of the liver and its appendages . . . 895 

Section I. — Diseases of the parenchyma of the liver * îb. 

Chap. I. — Lésions found in the liver after death . . . ib. 

Chap. II. — Symptoms of diseases of the liver . . . 902 

Art. 1 Local symptoms of diseases of the liver . . . ib. 

Art. 2. — General or constitutional symptoms . . . . 916 
§ 1. — Disturbances of digestion . . • .917 

§ 2. — Disturbances of circulation . . . . . 921 

A. Sympathetic disturbances of the circulation . . . 922 

B. Disturbances of the circulation occasioned by an obstacle to the 

free circulation within the liver . . • 924 
§ 3. — Disturbances of the sécrétions and of nutrition . .. .927 



U CONTENTS. 

Chap. III Cases ..... 

Art. 1 Sanguineous congestions of the liver 

Art. 2 — Altération of nutrition in the parenchyma of the liver 
§ 1 — -Observations on hypertrophy of the liver 
§ 2. — Observations on softening of the liver 
§ 3. — Observations on induration of the liver 
§ 4. — Observations on atrophy of the liver 
Art. 3. — Observations on accidentai productions in the liver 
§ 1. — Observations on abscesses of the liver . 
§ 2.— Observations on cancer of the liver 
$ 3. — Observations on hydatids of the liver 
Section IV.— Diseases of the passages for the excrétion of bile 
Book III. — Observations on peritonitis 
Section I — Acute peritonitis 

Chap. I. — Acute peritonitis terminating in death 
Chap. II. — Acute peritonitis terminating in recovery . 
Section II. — Chronic peritonitis 

Chap. 1. — Chronic peritonitis, acute at the onset 
Chap. II — Chronic peritonitis, chronic from the onset 
Section III. — Partial peritonitis . . 

Chap. I.— Epiploitis .... 
Chap. II.— Partial inflammation of the peritoneum, flanks, &c. 
Chap. III.— Partial inflammation of the peritoneum in the pelvis 
Chap. IV.— Partial inflammation of the sub-peritoneal cellular tissue 



PAGE 

929 



i 



CLINIQUE MÉDICALE: 

OR 

REPORTS OF MEDICAL CASES. 



DISEASES OF THE ENCEPHALON AND ITS 
MEMBRANES. 



FIRST BOOK. 

DISEASES OF THE ENCEPHALIC MEMBRANES. 
SECTION I. 

DISEASES OF THE DURA MATER. 

Case 1. — Fibrous végétation on the inrier surface of the dura mater, with considérable 
dépression of the part qf the brain corresponding to it — Hemiplegia — Intelligence 
perfect — Headach qf an old standing. 

A military man, sixty-one years old, entered the Hospital la Charité in the 
beginning of March, 1829. He appeared to have been of a good constitution, 
but when he presented himself, he was very much emaciated ; his countenance 
was of a pale colour, somewhat yellowish ; one half of the right eyelid was 
depressed before the globe of the eye, and it was incapable of being completely 
raised at the will of the patient ; both extremities of the right side vvere deprived 
of the power of motion, and their sensibility was impaired ; the urine was passed 
involuntarily ; puise remarkably slow. 

The patient stated that, after having experienced, for a long time, rheumatic 
pains in différent parts of the body, he was seized, about the beginning of the year 
1817, with a headach, seated principally towards the anterior part of the left 
pariétal bone. This pain was at first intermittent ; then became continued for an 
entire year ; then, from the middle of 1819, it disappeared altogether. This 
headach, the only thing the patient complained of, was at times insupportable. 
Nearly about the time it ceased, he thought the right upper extremity felt some- 
what more insensible than the left, as did also the fingers of this side from time to 
time ; they were cold, and usually presented a violet appearance. He gradually 
became unable to grasp anything with the right hand. Subsequently, the right 
upper extremity became completely paralytic, at the same time that the left lower 
extremity lost the faculties of sensation and motion. 

For the first ten or twelve days after entering the hospital the state of the 
patient did not change ; then the tongue became dry, and the puise fréquent j 

s 



2 



CLINIQUE MÉDICALE. 



his intellects became disturbed ; diarrhœa came on ; a broad eschav formed on the 
sacrum, and the patient died in an adynamic state towards the end of March. 

Post mortem. — Considérable emaciation. On raising the vault of the cranium, 
no appréciable lésion on the external surface of the dura mater. On making an 
incision, however, into it, this membrane was found to have contracted unusual 
adhésions to the subjacent parts. Thèse adhésions were formed by cellular bands, 
which united the two layers of the arachnoid to each other. Thèse bands cir- 
cumscribed a spherical body of the size of a large mit, which sank deep into the 
cérébral substance, with which it had not contracted adhésion in any other part. 
It was separated from it by a cellulo-vascular layer, which appeared to be the 
tissue of the arachnoid and pia mater compressed by it. This body was attached 
by a narrow pedicle to the inner surface of the dura mater, the fibres of the latter 
membrane being dispersed over the pedicle of the tumour, and so confounded 
with its tissue, that to distinguish them was impossible. This tissue, which was 
of considérable hardness, and of a white tendinous appearance, consisted of fibres 
which were, as it were, wound up one upon another ; they seemed a prolongation 
of the fibres of the dura mater. Some infarction in the posterior part of the 
lungs ; two white spots on the pericardium. The mucous membrane of the 
stomach, towards the great cul de sac, presented some red points ; the end of the 
ileum, and part of the colon, presented a bright red colour. 

Remarks. — From the nature of the symptoms and progress of the disease, one 
would have expected that softening was the lésion to be found in the brain in this 
case. That permanent flexion of the limbs oftentimes, though not always, accom- 
panying softening, was not how r ever here observed at any period. The rheumatic 
pains preceding the pain of head, might have led one to consider the latter also as 
rheumatic. There is not a doubt but that pain of head, similar to that we have 
described in this case, has been many times taken as the effect of neuralgia and 
rheumatism. The pain of head was here the first symptom observed, and it 
coincided probably with the commencement of the disease of the dura mater, and 
continued as long as the inflammatory process, necessary for the formation of the 
adhésions described in the post mortem, existed around the tumour, and ceased 
probably when the adhésions were changed into cellular tissue. The graduai 
manner in which the paralysis developed itself, was conformable to the nature of 
the disease ; it was not preceded by any loss of consciousness, and the intelligence 
was never disturbed. No lésion explained the incontinence of urine. A bright 
redness of the stomach, and a portion of the intestine, coincided in this case with 
the adynamic symptoms under which the patient sank*. 

Case 2. — Osteo-fibrous tumour, of the size of a pullefs egg, on the inner surface of 
the tentorium cerebelli, to which it closely adhères — Hemiplegia, with convulsive 
movements at intervais, on the sicle opposite that where the tumour was — Atrophy 
of the lobe of the cerebellum, corresponding to the tumour — Death by cérébral 
hœmorrhage. 

A shoemaker, forty-seven years old, addicted to spirituous liquors, fell on the 
occipital bone when drunk, about four years before entering the La Charité. 
Immediately after the fall he experienced no uneasiness. Subsequently, however, 
he began to feel a dull pain towards the left part of the occipital bone, which 
continued for a considérable time without becoming severe. Giddiness occurred 
also from time to time, often followed by total loss of consciousness, which never 
continued, however, beyond a few minutes. At a later period new symptoms 
presented themselves ; on a sudden, the upper extremity of the right "side was 
attacked with a painful, and as it were tétanie shock. Five or six of thèse 

* For some very interesting cases illustrating the effects of pressure from tumonrs see 
Dr. Bright' s Reports of Médical Cases, vol. ii. part 1. p. 342, &c. 



DÎSEASES OF THE ENCEPHALON. 



3 



shocks rapidly foliowed this, and during the three or four days following, the 
right arm continued torpid and somewhat weaker than that of the opposite side. 
At first there were intervais of months between thèse attacks ; they then becarne 
more fréquent, re-appearing every ten or twelve days, uniformly limited to the 
right arm, and at the same time paralysis of this limb, at first transient, became 
permanent, and more and more complète. Insensibly also the right lower extre- 
mity lost the power of motion ; it ne ver however exhibited any convulsive 
movement. Before entering the hospital he was attacked with giddiness, which 
becoming more severe, determined him on applying for admission. His state then 
was as follows : — 

The face and eyes injected ; some diniculty in articulating his words ; answers 
slow, but correct ; recollection clear ; diplopia from time to time ; commencing 
deafness. The patient complains of a dull pain towards the back part of the 
head, on the right side as well as on the left. The two extremities of the right 
side cannot be moved at the will of the patient ; they exhibit however a certain 
rigidity, and yesterday again the arm suffered five or six shocks, which caused the 
patient to suffer considerably. Puise very hard, but not fréquent. The pulsation 
of the heart strong. The muscular System even still remarkably well developed. 

Just when I had drawn up thèse détails, and we were going to bleed the 
patient, he was seized with ail the symptoms of apoplexy, and died the following 
day. 

Post mortem. — In the place ordinarily occupied by the left part of the tenforium 
cerebelli, there was found a large tumour which compressed the posterior lobe of 
the cérébral hémisphère of this side, and also the cerebellum. The structure of 
the cérébral hémisphère not changed, the tumour being principaUy developed on the 
side of the cerebellum, the en tire left lobe of which had undergone a most remarkable 
change, it being very much diminished in volume, and its substance having 
acquired extraordinary hardness. Neither the cerebrum nor cerebellum were 
continuous with the tumour. Interposed between them, and evidently produced 
at the expense of the dura mater, whose place it occupied, this tumour very much 
resembled that described in the preceding case, except that it contained in some 
parts a little calcareous deposit. In the right hémisphère of the cerebrum was 
found an enormous sanguineous effusion, which, occupying- the corpus striatum and 
optic thalamus, had made its way into the two latéral ventricles through the lace- 
rated septum. The parietes of the heart were hypertrophied. 

Remarks. — In this, as in the preceding case, the cerebrum was not ail affected ; 
but one of the lobes of the cerebellum, being compressed by it, underwent consi- 
dérable atrophy. Still none of those functional disturbances, which, according to 
authors, are connected with lésions of the cerebellum, were here remarked. The 
symptoms were just the same as if the tumour were seated in the cerebrum. The 
development of the osteo-fibrous tumour of the dura mater, seemed to be owing- 
originally to the fall which the patient had suffered several years previously. 



SECTION II. 

DISEASES OF THE ARACHNOID AND PIA MATER. 

There are few diseases whose symptoms présent so many varieties and so many 
individual différences as acute inflammation of the méninges. Are there well 
marked signs, by the aid of which we may readily distinguish during life inflamma- 
tion of the méninges lining the upper surface of the brain from that connected with 
the lower surface of this organ? Are there any spécial functional disturbances apper- 
taining to inflammation of the membrane lining the parietes of the ventricles ? By 
what signs can we recognise inflammation of the membranes lining the spinal cord ? 

6 2 



4 



CLINIQUE MÉDICALE. 



Whatever be its seat, can acute meningitis be distinguished by its symptoms, either 
from the other acute affections of the encephalon, in which tbis organ is found 
materially changed, or from those very fréquent cases in which irritation of the 
brain or its coverings, raerely sympathetic of irritation of some other organ, leaves 
no trace of its existence in the dead body ? In a word, in the dead body itself, what 
are the anatomical characters by whose aid we shall be enabled to afflrm that there 
really was acute meningitis in the cases where, during life, symptoms existed which 
seemed to belong to it? Such are the questions as yet undetermined in science, 
in the solution of which we think the following cases will assist. 



CHAPTER I. 

CASES OF DISEASES OF THE ARACHNOID AND PIA MATER COVERING THE UPPER 
SURFACE OF THE BRAiN. 

Case 3. — Effusion ofblood between the Arachnoid and Dura Mater. 

A coachman, seventy-three years of âge, of a strong constitution, had fallen 
from his seat nine years previously, and received a deep eut in the left temporal 
région, for which he was trepanned at the La Charité. He had not lost his con- 
sciousness from the fall, and after it he continued to enjoy perfect health. 

Towards the 20th March, 1822, he felt, without any known cause, both in the 
lower extremity and in the arm of the right side, a numbness, with difficulty in 
moving thèse limbs, pains also in the elbow and heel ; at the same time vertigo, 
ringing of the ears, headach, and somnolence. The following days there was 
graduai augmentation of thèse symptoms, and at length he became unable to 
follow his usual calling. Three days before entering the hospital the motions of 
the left lower extremity began to be difficult. 

When he entered the hospital on the 6th of April, 1822, he presented the fol- 
lowing state : — obstinate constipation, tongue natural. The two extremities of the 
right side could still perform some motions, but very feebly ; the left lower extre- 
mity was somewhat less weak than the right ; puise full and strong. Twenty 
leeches to the neck, friction on the limbs with camphorated spirits. 

On the 8th, a diminution of the vertigo, headach, and somnolence ; had two 
évacuations in twenty-four hours. Eighteen leeches to the neck, sinapisms to the 
legs. On the night of this day delirium set in. The following morning less pain 
of head, but the paralysis more marked. The three following days a graduai 
increase of the latter. On the 13th the countenance very much injected, drowsi- 
ness, pain on moving the right arm ; hemiplegia of the left side incomplète, whilst 
that of the right side is complète ; tongue red and dry, fseces and urine passed 
unconsciously ; puise strong and quick ; skin hot and dry (enemas and leeches 
to the neck, and blisters to the legs with diluent drinks). On the 14th, respiration 
stertorous ; total loss of consciousness ; coma. He died in the evening. 

Post mortem. The arachnoid, thickened and red, was detached from the dura 
mater of each side by an effusion of hlood, partly fluid and partly coagulated, 
which had completely dissected the serous membrane from above downwards, from 
the part adjoining the great faix of the dura mater to the temporo-parietal suture, 
and from before backwards, from the coronalfossa to theposteriorend of the pariétal. 
The detachment and effusion were more considérable on the left. The dépression 
of the hémisphères was nearly an inch on the left, only half an inch on the right, 
Beneath the effusion the cérébral substance was very firm. and presented very few 
bloody points, but the sinuses contained a considérable quantity. 



DISEASES OF THE ENCEPHALON. 



S 



Remaries. — We have here a rare case of pathological anatomy. ït is not easy 
to conçoive how a thin fine membrane, such as the arachnoid is, can be separated 
from the dura mater by effused blood without being torn. 

The symptoms here were altogether in relation to the seat and nature of the 
lésion. The prevailing symptoms existed at first with respect to motion ; there 
was double paralysis, as there was double effusion. It was not till a later period 
the intellectual faculties became disturbed. The hœmorrhage, slowly produced, 
acted at the same time by compressing and irritating the brain. 

Case 4. — Effusion of blood between the Arachnoid and Dura Mater — Graduai 
paralysis of the right side with permanent flexion. 

A man, seventy years of âge, of a lymphatico-sanguineous tempérament and 
weakly constitution, felt, for the îast two months, on the left side of the head, and 
particularly in the temporal fossa, a constant headach, which went on increasing 
up to the 4th of May. We could obtain no particular account with respect to the 
nature of this pain, and the symptoms accompanying it. We only know, that at 
the above mentioned period, the patient began to stammer, the tongue became 
embarrassed, intelligence seemed weakened, and in the morning the right side of 
the body was imperfectly paralysed. This hemiplegia made very slow progress 
on the following days. There was added to it continued fever with adynamic 
symptoms. When brought to the hospital on the J5th of May, he presented 
the following state : — Prostration, lying on his back, pupils equally moveable, 
countenance very flushed, features drawn to the right, lips dry, tongue red, dry, 
cleft, trembling, but no déviation to either side ; breath fetid, stools and urine passed 
involuntarily. Considérable heat of skin, with moisture ; puise strong, full, and 
fréquent. The extremities of the right side présent a paralysis of motion, but not 
of sensation. To this is added, in the upper extremity, strong contraction of the 
flexor muscles of the fore-arm on the arm ; the patient seems to understand what 
is said to him, but he answers very indistinctly, Great drowsiness (two blisters to 
the right lower extremity, one to the thigh, one to the leg). On the 16th and 
17th, graduai increase of the hemiplegia; the rigidity of the upper extremity 
continued up to the 20th, when there was observed stupor, stertor, total extinction 
of intelligence (twenty-five leeches to the neck, two sinapisms to the feet). On 
the 21st the rigid contraction of the right arm ceased, total extinction of motion 
and sensation on the right side, breathing stertorous, eyes dull, pupils equally 
moveable, puise continually full and strong, skin hot and moist (sixteen leeches to 
the neck). Died at ten o'clock at night. 

Post mortem. The vessels uniting the bones to the dura mater appeared very 
much injected on the left ; on dividing this membrane, we found between it and 
the arachnoid, along the posterior three-fourths of the latéral wall of the cranium, 
and from its base to the faix of the dura mater, an erTusion of blood, partly liquid, 
partly coagulated, black, depressing the serous membrane for nearly an inch at the 
centre, gradually diminishing in thickness to the circumference. The two folds 
of the arachnoid were red and thickened. The cérébral substance of the two 
hémisphères were dotted with blood ; a little sérum in the ventricles ; heart very 
soft and rlaccid ; brownish colour of the gastric mucous membrane, towards the 
great curvature. 

Remarks*. — One of the most curious circumstances in this case is, that the 
symptoms connected with it, very much resemble those occurring ordinarily in 
softening of the brain. Thus, the disease commences by a cephalalgia fixed to 
one point of the head ; then the intelligence becomes impaired ; subsequently the 
limbs opposite the side of the head affected with pain become gradually weakened. 
and ultimately the paralysed limbs présent a well marked contraction. Ail thèse 
are the signs of softening of the brain — still not the slightest trace of this altération ; 
nothing being found but a collection of blood between the dura mater and 
arachnoid, the iatter being also thickened and diseased. 



6 



CLINIQUE MEDICALE. 



Case b.— -Partial Meningitis — Erysipelatons phlegmon of the neck supervening on 
a contusion of this part — Signs of arachnitis only during the last hours of life. 
A postilion, thirty-three years of âge, of a strong constitution, received, on the 
2nd February, 1822, on the right side of the neck, a very heavy sack of oats, which 
fell on him from a height of several feet. He, however, continued his customary 
occupation till the 7th. He felt a painful tension on the right side of the neck, 
at which part the skin assumed an erysipelatous appearance ; fever came on, and 
the patient kept his room. The fever continued on the 8th, 9th, and lOth, and the 
erysipelas spread. On the Util he entered the hospital, when the fever was very 
high ; the neck was covered with leeches. Desquamation commenced at several 
points of the skin of the neck ; but on the right, behind the sterno-mastoid muscle, 
an obscure fluctuation was observed ; this muscle also seemed more prominent 
than that of the opposite side ; no other morbid symptom ; no stool for three 
days. At one o'clock in the morning the patient suddenly became délirions. 
On the 12th, ateight o'clock, the delirium still continued ; eyes haggard, constantly 
rolling ; pupils very much contraeted ; violent screams ; free motion of the limbs ; 
puise fréquent and very weak ; tongue moist and red ; burning thirst ; no stool ; 
some leeches applied the prececling day still bleeding (blister to one thigh, 
sinapisms to the legs, purging enema, acid drink). Three hours after the visit he 
expired. 

Post inortem. Arachnoid and pia mater natural in every respect, except for the 
space of three Angers' breadth in length, and two in vvidth, near the anterior 
extremity of the upper surface of the left hémisphère of the brain. There the 
membranes were thickened and red. A small quantity of limpid sérum in each 
latéral ventricle ; the posterior part of the two lungs infarcted ; the mucous 
membrane of the stomach presented, at the pyloric portion, a slight brownish tint ; 
the spleen very soft ; a great quantity of pus infiltrated the cellular tissue beneath 
the sterno-mastoid muscle of the right side. 

Remaries. — This is a very remarkable case. It is probable that the partial 
arachnitis, ascertained in the dead body, commenced only with the delirium ; the 
disturbance of the intelligence, and a striking contraction of the pupils, were the 
only two phenomena occasioned by this inflammation; at times thèse very slight 
inflammations of the méninges are sufficient to disturb the intellect. We may note 
also, that here the inflammation was seated at the anterior and superior part of one 
of the cérébral hémisphères, where, in fact, several physiologists more particularly 
place the seat of intelligence. But why this contraction of the pupiJs ? What 
relation between an irritation so slight, and so well circumscribed, of a very small 
portion of the méninges, and the movements of the iris ? The nervous centres 
may then be injured in their functions, without the anatomist being able to discover 
any altération. 

Case 6. — Acute Meningitis limited to the convexity of the left hémisphère ofthe brain 
— Delirium. — Convulsive movements ofthe face and extremities of the right side. 
A tailor, thirty-seven years of âge, had been sick for four or five days when he 
entered the hospital, 17th July, 1821. On the loth of this month, without any 
known cause, he was seized with violent pain of head, particularly seated in 
the frontal région. On the day after, the headach continued, and the pain 
became more gênerai, being extended now to the pariétal and occipital resions. 
On this day he lost his appetite, and vomited some drink he had taken. In the 
evening, constant nausea still appeared, followed from time to time by a throwino- 
up of some bitter yellow matter. On the 17th, the headach still continued, 
but the vomiting ceased ; some nausea still. Having entered the hospital, he 
presented, on the next day's visit, the following state :— face remarkably pale ; 
pain of head, the précise seat of which cannot be pointed out by the patient ; at 
intervals this became so very seyere as to make him utter piercing cries ; eyes 



DISEASES OF THE ENCEPHALON. 



dira and languid ; slight involuntary motion of the muscles which move the com- 
missure of the lips ; his answers accurate ; gives a perfect account of his state, and 
of eveiy thing which happened to him since the commencement of his illness ; the 
puise moderately fréquent, and regular ; everything else natural. 

It was difficult to assign a précise seat to tins group of symptoms ; the flr.st 
complaints, however, regarded the head ; the vomiting might be considered as 
connected with a commencing cérébral affection, and the severe headach 
seemed to point out the head as the seat of the disease. The absence of any 
morbid phenomenon, with respect to the alimentary canal, repelled the idea that 
the headach was sympathetic of gastro-intestinal irritation. The absence of ail 
fébrile disturbance precluded the possibility of its being mere continued fever. 
The state of the patient, however, appeared very alarming ; the appearance of his 
countenance, and, amidst this absence of local symptoms, the great altération 
already of his features, obliged us to form a rather unfavourable prognosis. M. 
Lerminier suspecting a state of encephalic congestion, applied, notwithstanding the 
extrême paleness of his face, twenty leeches across each jugular vein. Demulcent 
drinks, and sinapisms to the lower extremities. No change in the patient on the 
following morning. 

On the 20 th, he was very much cast down, and answered questions with diffi- 
culty and reluctance ; light was painful to him ; he kept his eyes closed, and his 
head concealed under the bed-clothes ; face very pale ; pain of head not great ; 
the convulsive movements of the lips more fréquent and more marked ; puise and 
skin natural (blister to the nape of the neck). In the nîght he emerged from a 
state of stupor, in which he had been for the last twelve hours. He got up out of 
bed suddenly, saying that some persons were pursuing him to do him harm. He 
raved during the night, and occasionally uttered several piercing cries. 

On the 21st, he was kept in bed by force. The face had now become red ; 
the head was agitated by a continuai movement, which carried it from right to 
ieft, and left to right ; the muscles moving the lips, the aise nasi, and the eyebrows, 
were in the highest degree of convulsive agitation ; saliva, slightly frothy, flowed 
in great abundance from the mouth ; he spoke incessantly and with energy, but 
his articulation was un intelligible ; great subsultus tendinum, which prevented the 
puise from being felt ; its frequency did not seem very great (bleeding from the 
arm, twenty leeches to the neck. cold applications to the head). No change on 
the 21st. 

On the 22nd, violent delirium ; convulsive motions of the muscles of the face ; 
risus Sardonicus ; continuai motion of the right arm ; subsultus increased ; puise 
more fréquent ; tongue nioist and red (two blisters to the thighs ; ice to the head). 

On the 23rd, head turned back, and to the right; strong contraction of the 
right arm ; respiration very irregular ; occasionally accelerated ; it then becomes 
slower than natural. The patient silent, and quite still ; eyes fîxed, and void of 
expression ; mouth open and unmoved ; pupils neither contracted nor dilated ; 
answers no questions ; does not even seem to understand them ; original paleness 
of face returned ; puise sixty a-minute, and regular ; bowels not free ; tongue 
cannot be seen ; teeth not dry. He remained quite torpid during the day, but at 
night violent delirium reappeared ; uttered very loud cries. 

On the 24th, this excitement was succeeded by profound coma ; extremities 
cold ; a clammy sweat covered the face ; respiration râlant. Died in the course 
of the day. 

Post mortem. — On the upper surface, a considérable différence in the colour of 
the two cérébral hémisphères, the right being pale, whilst the left presented a 
well-marked red tint, which resided entirely in the subarachnoid cellular tissue, 
which was traversed by numerous vessels ; neither sérum nor pus in this tissue ; 
the grey substance constituting the most superfîcial portion of the convolutions 
of the left hémisphère participâtes in the injection of the pia mater covering 



e 



CLINIQUE MEDICALE. 



it. The ventricles contained scarcely two spoonfuls (cuillerées a cafe) of sérum ; 
nothing remarkable in the rest of the brain. The lungs infarcted posteriorly ; 
the heart contained in its right cavity a large fibrinous clot, deprived of its 
colouring malter ; the mucous membrane of the stomach very thin towards its 
great cul-de-sac. 

Remaries. — This case présents an example of acute meningi.tis more extensive 
than the preceding case, but still partial ; it occupies, in fact, but one of the sides 
of the brain, the médian line accurately limiting it. The first symptom was pain 
of head, which was of long duration and remarkably severe. This, after a little, 
was complicated with gastric symptoms, which appeared entirely the sympathetic 
resuit of the brain affection. The nausea and vomiting arose from the disturbance 
of innervation, but thèse sympathetic phenomena soon disappeared. The brain 
symptoms gradually became worse. The intelligence, also, so perfect when he 
entered the hospital, became gradually disturbed. The slight convulsive move- 
ments of the lips were soon succeeded by convulsions of the entire face and of the 
right arm, which latter was ultimately found to be permanently flexed. The dis- 
turbance in the motion of the right arm might cause us to anticipate thatthe opposite 
side of the brain was the seat of the disease ; the pain of head not being confined to 
the afFected part of the cérébral membrane, could not assist in determining it. 
The therapeutic means adopted seem to have had no influence whatever on the 
disease. A little more blood than natural, accumulated in a circumscribed portion 
of the pia mater, was enough to destroy the nervous fonctions, and ultimately life. 

Case 7. — Meningitis limited to the anterïor extremity of each cérébral hémisphère — 
Rosy tint and slight softening ofthe subjacent grey substance — Follicular enteritis 
procecding towards a cure — Symp)toms of ataxic fever, 

A boy, seventeen years of âge, entered the hospital February ISth, 1824, with 
s3 r mptoms of slight continued fever ; headach ; tongue white, moist, slightly red 
at the point and edges ; thirst considérable ; constipation ; no change in his 
state for the five or six days following, during which interval he was bled from the 
arm, and twenty leeches were applied to the anus. 

On the 24th, we were struck with the air of distraction in the patient's counte- 
nance ; he answered questions with difficulty, and appeared to be absorbed in 
thought. 

On the 25th he was sunk in stupor ; pupils perceptibly dilated ; tongue natural ; 
puise small and fréquent ; skin hot (twenty leeches to the neck). During the two 
following days no change. 

On the 28th he emerged from the stupor, became restless, and spoke continually. 

March lst, stupor returned ; dilatation of the pupils extrême ; tongue quite 
natural ; puise very small and fréquent ; notwithstanding the torpid state of the 
patient, the cutaneous sensibility was very much increased ; he complained when- 
ever we touched the skin, particularly on the thorax and abdomen ; he pushed the 
hand which touched him, and complained of pain (leeches again to the neck, and 
blisters to the legs). He died the next night. 

Post mortem. — Fulness of the veins traversing the convexity of the cérébral 
hémisphères ; the portion of the pia mater covering the anterior extremity of each 
of the hémisphères very much injected ; rose-coloured tint, together with slight 
diminution in consistence, of the cortical substance in contact with the pia mater 
at this part of the brain. No other appréciable altération in any part, except that 
the lungs contained some small granulations not resembling those usually met 
with, which, when eut into, allowed a small quantity of limpid sérum to escape. 
The inner surface of the stomach was very white, except one small spot, which 
was red, and seemed formed by the aggregation of small vessels finely injected. 
In the small intestines several of the follicles were more developed than natural •; 
some single, and others aggregated together, constituting what are called Peyers 



DISEASES OF THE ENCEPHALON. 



9 



glands ; they presented black points, and projected somewhat, beyond the level of 
the mucous membrane. 

Remarks.— This is another case where inflammation of the membranes existed 
only in a very small extent of the external surface of the brain. The pia mater 
was injected merely towards the anterior and upper part of each hémisphère ; and 
in this part the grey substance of the circumvolutions participated in the irritation 
of the membrane covering it. This is ail that was found to explain the serions 
nervous disturbances which manifested themselves on the last days of the patient's 
life. No doubt but the patient died in conséquence of the lésion of the nervous 
centres. The entire disease, however, did not réside here ; for, on entering the 
hospital, nothing manifested itself but mere continued fever, without any vvell 
marked local symptom ; the intestine was then diseased, and we doubt not but 
that, at first, there was follicular enteritis, which was in progress of cure, as 
appeared from the post inortem ; then the partial meningitis supervened, which 
rapidly gave the most serious character to a disease till then mild. 

Case 8. — False membranes of récent formation on the arachnoid, Uning the convexiiy 
of the left hémisphère — No other appréciable lésion of the méninges — Headach 
at the ontset — Delirium — Tubercles in the langs and spleen. 

A man, forty-three years of âge, entered the Hospital la Pitié at the commence- 
ment of the month of April, 1831, presenting the ordinary symptoms of pulmonary 
phthisis. On the 19th of May he complained of an acute pain, seated in the 
left temporal région. This pain, which was not increased by pressure, became 
occasionally insupportable, and then radiated towards the pariétal and orbital 
régions of the same side of the head. This was the first time he complained of 
such a pain ; it had appeared the night previous, and prevented hira from enjoy- 
ing a moment's sleep. No other change in the state of the patient ; the puise was, 
as we usually found it in the morning, from 70 to 80 ; no appréciable disturbance 
in sensation or motion. This pain, then single, and unaccompanied by any other 
symptom, was considered mere temporal neuralgia, and nothing particular was 
prescribed. However, the following day and night the patient suffered dreadfully in 
the temporal région. On the 20th of May, though seeing no reason to change our 
diagnosis, we had him bled from the arm to twelve ounces ; the blood, examined 
the next day, consisted of a small clot ; rather black, without any appearance of 
the burry coat, and encompassed by a great quantity of sérum. The pain of the 
left temple had not diminished ; no other new symptom manifested itself. On 
the 21st, still headach ; no change at ail ; twenty-four leeches were applied to 
the left mastoid process, which bled freely ; still the headach as intense as 
ever. Still conceiving the affection to be a neuralgia, we applied an opium 
plaster to the left temple, and ordered a grain of hyoscyamus to be taken inter- 
nally. On the 23rd, 24th, and 25th of May, no change ; but on the 26th we 
remarked, for the first time, that the skin of the two eye-lids, as also those of the 
cheeks, was raised by sérum accumulated in the cellular tissue ; this skin still 
preserved its natural colour ; headach still continuing ; the puise was, as usual, 
80 ; a blister was applied to one of the lower extremities. 

On the night of the 27th, the intellect disturbed for the first time ; he arose 
from bed, and became very noisy. Towards morning the delirium ceased, and at 
the visit we found him as usual, except that he complained less of the temple. 
On the night of the 28th, the intellect again disturbed, and delirium returned ; 
in the morning he answered questions very incoherently ; the œdema of the face 
increased. without the skin being red ; puise 88, and the température of the skin 
raised. In the course of the day the patient became comatose, and died on the 
29th. 

Post mortem twenty-nine hours after death. — The cranium being raised, and the 
dura mater divided, we found covering the convexity of the left hémisphère of the 



10 



CLINIQUE MEDICALE. 



brain, at the point of union of the middle and anterior lobes of this hémisphère, a 
whitish false membrane, soft and not yet presenting any character of organisation, 
and merely in apposition with the arachnoid, to which it did not adhère. This 
false membrane was somewhat broader than a nve-franc pièce. On other points 
of the arachnoid, of the same side, there were deposited as it were small drops of 
white, thick pus, which we raised on the back of the scalpel. Two or three such 
drops were found on the portion of the arachnoid covering the left surface of the 
great faix cerebri ; no other appréciable altération in the arachnoid or brain. In 
the thorax were numerous tubercular masses, some of which were softened. The 
internai surface of the stomach presented a slate-colour tint, with papillary thick- 
ening of the mucous membrane along the great curve. About a qnarter of the 
spleen converted into a large tubercular mass. 

Remarks. — This is one of those rare cases wherein the arachnoid, properly so 
called, is the seat of the disease. It is in fact in its cavity that the morbid prq- 
ducts existed. On the right eyery thing remained in the most natural state. It 
is a case of real arachnitis, similar in every respect to inflammation of serous 
membranes elsewhere. This inflammation of the arachnoid will easily explain the 
différent nervous symptoms during life. Thus the pain which affected the left 
temporal région so long and so severely, was not a mere neuralgia. It marked the 
commencement of the .arachnitis, and for a long time continued sole, and it was 
only towards the end, that more decided symptoms of arachnitis appeared, first 
delirium and then coma, which was followed by death. 

Case 9. — Partial me?ii?igitis — Tubercles in the pia mater, and in other organs ; adhé- 
sions of two circumvolutions — Headach at first; afterwards delirium ; contraction 
of the muscles of the neck ; paralysis of some muscles of the face. 

A man, nineteen years of âge, on entering the La Charité, complained of a 
violent headach, principally seated towards the right temple, under which he lias 
been labouring now twelve days; His intellect perfect ; he constantly lies on the 
left side. Puise slow (sixty a minute); the pupils a little dilated; countenance 
expresses an air of indifférence ; tongue natural ; has some difBculty in passing 
urine. This group of symptoms make us apprehend the development of a céré- 
bral affection ; he was ordered to be bled from the foot, and forty leeches to be 
applied to the neck. The day after (14th March) the air of indifférence was 
succeeded by complète delirium ; the head remained constantly inclined to the 
right ; puise now seventy-two. He was bled from the arm. In the evening he 
can now answer questions tolerably, which he could not in the morning. When 
we attempt to incline his head to the left, he évinces pain ; the right side of the 
mouth then opens, whilst the left half remains unmoved. 

March loth. Look fixed; head still inclined to the right; delirium still con- 
tinued ; air of stupor ; puise more fréquent than on the preceding days ; tongue 
natural ; abdomen free from pain ; no évacuation by stool (thirty leeches to the 
neck, laxative enema). Whilst the leech-bites were still bleeding, the pupils, 
which till then had remained dilated, contracted in a very remarkable manner. The 
puise became very fréquent, irregular, and small ; the mouth became filled with 
foam ; the trachéal râle set in, and the patient died at half-past twelve at noon, 

Post mortem. — The pia mater covering the upper surface of the cérébral hémi- 
sphère, contained about twelve small whitish granulations, the size of a lentil, and 
of cartilaginous consistence. They were found between the convolutions. On the 
middle latéral part of the right hémisphère, w r as observed a bright red injection 
of the pia mater, for a space as large as two five-franc pièces put together. 
Between two circumvolutions of the middle latéral part of the left hémisphère, 
was found a white tubercle of the size of a large pea, softened at its centre. Thèse 
two convolutions had contracted intimate adhésions, and were confounded with 
each other. Numerous tubercles in a crude state traversed the lungs. The îym- 



DISEASES OF THE ENCEPHALON. 



11 



phatic ganglions of the posterior mediastînum also tuberculated. Three srnall 
tubercles in the spleen. 

Remarks. — Of the altérations found after death in the body of this patient, some 
were dated from a period inuch. prior to the attack of the disease under winch he 
fell. Such were the tubercles in the pia mater, in the lungs, in the lymphatic 
ganglions of the posterior rnediastinum, and in the spleen. The adhésion also of 
the two convolutions of the left hémisphère was a lésion of long standing, and 
prior to the disease observed by us ; to explain the latter, then, we hâve but the 
injection of the pia mater in a very small portion of its extent, without any other 
altération of this membrane, or of any other part of the encephalon. When the 
lésions were so slight, and the symptoms so severe, who would dare to affirni that 
thèse lésions représentée! everything that did exist, and that anatomy showed us 
every thing that was materially altered in the nervous centres ? Certain it is that 
the only appréciable altération of récent formation, discovered on opening the 
body, existed in thèse centres ; and it was here also during life, that the entire 
disease seemed to réside. For a considérable time it appeared unattended with 
anything serious ; an obstinate headach, situated towards the point where, after 
death, we found the pia mater injected, was for the first twelve days, the pre- 
vàtling symptom. When we saw the patient, his intelligence was perfect, his 
faculties of motion and sensation were unimpaired, and he had no fever. Still 
from the very first we were struck with his position when in bed, and this pheno- 
menon, added to the air of indifférence expressed in his countenance, directed our 
attention to the brain. On the following days the disease, which had been at first 
mild, was accompanied by most marked and alarming nervous symptoms. 
Belirium, partial paralysis of the muscles of the lips, painful contraction of the 
muscles of one side of the neck, particularly engaged our attention. Whilst 
thèse phenomena were developing themselves, the puise became acceleratecl, the 
tongue preserved the most natural appearance. In this case the most active 
antiphlogistic treatment was employed. During the three days the patient re- 
mained in the hospital, he was bled twice, and seventy- leeches were applied to his 
neck. Still the most serious symptoms supervened every day, and we shall even 
remark, at least as a mere coincidence, that it was immediately after the applica- 
tion of the last leeches that the struggle commenced. Had the loss of blood any 
share in the symptoms which appeared during the last hours of life ? we would 
be inclinée! to think it had. 

Case lO.— Mïiïy infiltration of the pia mater on the upper surface of the cérébral 
hémisphères — Turbid sérum in the great cavity of the arachnoid — Suppuration of 
the pituitari/ gland — Végétations on theaortic valves, with production of encephaloid 
matter at their base — Delirium — Hurried resjiiration — Pleurosthotonos. 
A man, sixty-four years of âge, was brought to the La Charité on the 27th of 
May. Those who brought him stated that he was ill for the last fourteen days, 
but gave no other information regarding him. On the next day he presented the 
following state : — Countenance very pale and dejected ; lies on his back ; œdema 
around the ankle:-; ; delirium ; complains continuaîly ; voice weak and trembling ; 
respiration high, hurried, very painful, as if there were some obstacle to the free 
entrance of the air into the pulmonary vesicles ; no lésion, however, detected by 
auscultation in the lungs ; the air appears to penetrate in every part ; the puise, 
being very small, contrasts with the strength of the pulsations of the heart, which 
are accompanied with a well-marked bruit de soufllet ; tongue natural ; abdomen 
soft (diluent drinks, sinapisms). On the "29th, his entire body strongly inclined 
to the right ; the muscles of the neck, and those of the trunk of the same side, 
being spasmodically contracted, prevented the neck and head from being brought 
into the straight position ; still less could they be made to devîate to the left. To 
thèse symptoms of pleurosthotonos were joined delirium, great dyspnœa, extrême 
frequeney of the puise, which was' at the same time thready. Died at noon. 



12 



CLINIQUE MÉDICALE. 



Post mortem. — Body very much emaciated ; œdema of the lower extremities. 

Cranium. — The great cavity of the arachnoid contained a considérable quantity 
of milky sérum ; the pia mater lining the upper and latéral surfaces of the cérébral 
hémisphères was infiltrated with liquid similar to thick cream ; no trace of the 
pituitary gland to be found in the sella turcica ; in its place there was a collection 
of pus*. 

Thorax. — Lungs and pleuras sound ; a little sérum in the pericardium ; right 
cavities of the heart distended by an enormous clot of blood ; one of the aortic 
valves had, on its ventricular surface, a greyish végétation, easily detached with 
the scalpel from the tissue on which it rested ; another of the aortic valves had 
entirely lost its usual appearance ; it was changed into a reddish mass, and to- 
wards its point of union with the internai membrane of the vessels, the latter pre- 
sented an évident fluctuation ; a slight incision was made on the point where this 
fluctuation existed, and there escaped between the lips of the incisions a chocolate- 
coloured matter, of a softish consistence, like a mixture of blood and cérébral mat- 
ter. It is more probable that this was blood efFused and altered, than the resuit, 
of a morbid sécrétion. 

Remarks. — In this case, which we had not the opportunity of seeing till a very 
advanced stage, the membranes were more seriously affected than in any of the 
preceding. First, they were changed to a greater extent ; then there was not 
only hyperemia, but purulent sécrétions on the two surfaces of the arachnoid, and, 
what is most unusual, suppuration of the pituitary gland. 

The symptoms first observed were those usually accompanying meningitis of 
the convexity of the hémisphères. How shall we account for the pleurosthotonos, 
whilst the lésion of the membranes was the same on the right and left ? The 
principal cause of the difficulty of respiration appears to bave been the altération 
of the sigmoid valves of the aorta. This was probably the cause of the bruit de 
soufflet. 

Case 11. — Purulent infiltration of the sub-arachnoid cellular tissne of the upper and 
inner surface of the two cérébral hémisphères — Bright red injection circumscribed 
to the middle lacerai portion of the left hémisphère — Tubercle in the brain — Pain 
ofhead; hemiplegia of the right side ; dulness ; vomiting ; infrequency of pidse. 
A boy, seventeen years old, felt for the preceding fifteen days violent pains of 
the head, and experienced for the last two days only commencing weakness in the 
lower extremity of the right side, when he entered the hospital on the 24th July 
1822. His state then was as follows : — Countenance very pale, slightly puffed ; 
pupils natural ; vision and intelligence perfect ; the lower extremity of the right 
side seems to the patient heavier than the left. Since the preceding night only 
he began to feel some difficulty in moving the upper extremity of the right side, 
and it seems heavier to him than the other ; the sensibility of both thèse limbs, 
however, is unimpaired ; pain of head very acute, and occasionally extorts loud 
cries from the patient ; puise irregular, but not fréquent ; respiration high, and the 
intervais between each inspiratory movement unequal (twenty leeches behind 
each ear, sinapisms to the legs). A few hours after the visit the patient fell into 
a profound stupor. The following morning, 25th July, the coma disappeared ; 
intelligence perfect ; answers précise ; pain of head continues ; paralysis of the 
righ t side increased ; puise very irregular, and fifty each minute ; vomited a green 
bitter matter twice or thrice during the night ; tongue still the same (thirty leeches 
to the neck, two blisters to the legs). On the visit of 26th sunk into a profound 
coma ; his countenance, however, indicates pain, when the limbs are pinched ; 

* From the situation of this organ, which is such as to protect it from injury, it is probable 
that there are some very important functiom assigned to it, with the nature of which we are 
totally unacquainted. Considérable importance has been attached to it as connectée! wkh 
epdepsy. Dr. Bright mentions a case, vol. ii. p. 301, where it was wanting. 



DISEASES OF THE ENCEPHALGN. 



13 



puise préserves its slowness and great irregularity ; skin cool and moist (a blister 
to the nape of the neck). On the 27th, eyes open, but immoveable ; vision appears 
to be gone ; he seems not to understand any thing ; and articulâtes not a word 
(stimulating frictions to the limbs ; ice to the head ; sinapisms to the legs). On 
the 28th, puise ninety-six. On the 29th, other symptoms appear ; the eyes and 
face are become the seat of slight convulsive twitches, which are repeated at short 
intervals ; côma not increased ; he stares at those questioning him, without answer- 
ing ; distinguishes objects well ; complains very much ; retracts the arm a littie 
when it is pinched ; this arm when raised falls as an inert mass, whilst he holds 
the left arm raised without any effort ; puise eighty ; the respiration proportion- 
ally more accelerated than the circulation (ice to head continued). On the 30th, 
the intelligence returned, the patient answers questions, hears and sees perfectly ; 
puise ninety-two, and the respiration still accelerated ; paralysis of the right side 
continues. On the Slst, the patient, whose state for the last two days was so 
perceptibly improved, relapses into coma ; during the day the respiration, which 
is now accompanied with a raie, becomes more and more accelerated, and the 
patient expired, as if in a state of asphyxia, during the night. 

Post mortem. — The pia mater covering the upper surface of the two hémisphères 
was infiltrated with a thick purulent laver ; the arachnoid itself being in its natural 
state. On the left, below the pia mater, near the great interlobular fissure, 
several circumvolutions présent a bright red appearance ; some even présent a 
uniform red tint; the tissue of the circumvolutions in other respects natural ; out- 
side the left latéral ventricle, on a level with the ancyroid cavity, the cérébral 
substance contains a tubercle the size of a large pea, developed in a mass of grey 
substance. Tubercles were found in great numbers in the two lungs. 

Remarks. — In this case the membranes were not only injected, they were also 
the seat of purulent sécrétion. One of the most striking of its symptoms was the 
paralysis of one side of the body, which developed itself from the commencement 
of the disease, and went on increasing. It seemed as if the left hémisphère of the 
brain was subjected to some compression, and yet such did not appear. The 
purulent layer between the arachnoid and brain was on both sides ; on the left 
only some of the circumvolutions participated in the irritation of the membranes, 
inasmuch as they were considerably injected. If that were the cause of the para- 
lysis, why was it not preceded by a state of contraction of the limbs, as happens 
very often in inflammations of the cérébral pulp ? Beside this permanent symptom 
we find others remarkable for their appeariug and disappearing alternately ; thus 
the intelligence went and returned ; the very evening before death it was quite 
perfect ; still it is very probable that thèse lésions in the pia mater, which we dis- 
covered the following day, existed at that time. Several times also the patient 
fell into a state of coma, which is considered as appertaining to inflammation of 
the méninges covering the lower surface of the brain ; and this coma was also 
moveable as the delirium. The sight also went and returned. Was it not 
strange that thèse functional disturbances were but transie nt, whilst the lésions 
causing them were permanent'? In such a case it must be admitted that thèse 
symptoms depended less on the cérébral membranes themselves than on the way 
in which the cérébral pulp was affected at différent periods of the disease by the 
irritation of the membranes enveloping it. Thus in pericarditîs the variability, 
mobility, and oftentimes also the transient nature of the symptoms dépends on 
this, that the heart in ail persons, or in one and the same person, during the entire 
course of the disease, is differently affected by the irritation of its investing 

membrane. No altération in the pulmonary parenchyma, nor in its investing 

membrane accounted for the very great disturbance of the respiration that was 
observed. The symptom, as also the vomiting that took place, must have 
depended on the cérébral affection. 



14 



CLINIQUE MEDICALE. 



Case 12.— Abuse of spirltuous liquors— -Pleuro-pneumonia at the outset — Fébrile 
delirium — Emphyment of opium in a large dose — Purident infiltration of the 
sub-arachnoid cellular tissue of the convexity of the hémisphères. 

A coachman, forty-eight years of âge, addicted very much to alcoholic liquor, 
was received into the La Charité on the 25th of September. He then complained 
of a pain below the left mamma. On the posterior and inferior part of this side, 
a well marked crepitating râle was heard, and the sound in this part also was dull. 
The patient coughed frequently, and expectorated transparent viscid sputa, 
which were slightly streaked with blood. He had considérable fever. Three 
days previous, this person, being till then in good health, was seized with a violent 
shivering; then pain of side, oppression, and cough became manifest. Thèse 
symptoms of pleuro-pneumonia were met by bleeding from the arm to sixteen 
ounces, and the application of twenty leeches to the side, which was done 
immediately after the bleeding. The blood taken from the veins exhibited the 
buffy coat. On the following day there was an évident amendment. On the 
night of the 26th the patient was suddenly seized with delirium. On the 27th, 
the delirium still continued; the gênerai symptoms of pleuro-pneumonia were 
gone. Fever still. He was bled to twelve ounces ; blood buffed. 

His state on the 28th still the same (thirty leeches to the neck). On the 29th, 
delirium still continued. Guided as wcll by the existing symptoms, as also by 
knowing the previous habits of the patient, we began to suspect that the case was 
one of delirium tremens ; we determined to try opiates, and ordered ninety-six 
drops of Rousseau's laudanum to be given in two doses. He took the first without 
any perceptible effects ; in two hours after he took the other, and soon fell into a 
tranquil sleep till the following morning. He awoke at the visiting hour, and 
answered, with précision, the questions addressed to him, and again fell asleep ; 
he awoke in the afternoon in the full possession of his reason. On the Ist of 
October there was considérable fever, which was accounted for by pulmonary 
engorgement, detected in the posterior and left side of the chest, the crepitating 
râle being distinctly heard here ; the use of opiates was suspended. On the 3rd, 
the crepitating râle was still heard, and in the evening the fever was much 
increased. On the 4th, the puise very fréquent, and a tendency to delirium 
re-appeared ; two blisters to the legs. However, in the course of the day, ail 
tendency to delirium disappeared, and the puise became less fréquent. The 
three days following the intelligence became perfect, and every thing became so 
favourable, that he appeared likely to be able to leave the hospital very soon ; when, 
on the 9th, his intelligence again became disturbed, and the puise was somewhat 
accelerated ; upon which, an anodyne potion, containing a scruple of laudanum, 
was prescribed ; two blisters were applied to the thighs, and sinapisms to the lower 
extremities, but without any benefit. On the 17th, 18th, and 19th, the delirium 
became complète. On the 20th, the tongue, for the first time, lost its natural 
appearance ; it became red and somewhat dry. The -«eeven days following, 
continuai delirium, increasing prostration ; tongue dry and brown : fœces passed 
involuntarily ; puise fréquent and small ; rapid emaciation of the face. He died 
on the 27th of October. 

Post mortem. — A turbid milky sérum infîltrated the sub-arachnoid cellular tissue 
of the convexity of the hémisphères in considérable quantity. The latéral 
ventricles contained but a small quantity of limpid sérum. In the thorax, cellular 
bands closely united the pleura costalis, and pleura pulmonalis of the left side. A 
great quantity of frothy sérum gushed out of the tissue of the two lungs ; this 
tissue also retained the impression of the fmger like an œdematous limb. The 
pericardium adhered close to the heart by a dense cellular tissue, whose formation 
must have been anterior to his entering the hospital. Nothing particular in the 
abdominal viscera, except that the splenic portion of the stomach was considerably 
dilated, and the pyloric portion contracted. 



DÏSEASES OF THE ENCEPHALON. 



16 



Remarks. — When the patient entered the hospital he presented ail the symptoms 
of pleuro-pneumonia, except the c'haracteristic sputa, which were wanting, as 
sometimes happens. Active antiphlogistic treatment soon dissipated ail the 
symptoms except the crepitating râle, which was still heard. Delirium then set in, 
which was met by vensesection, leeches to the neck, and révulsives to the lower 
extremities. To relieve this state, one hundred drops nearly of Rousseau's 
laudanum were administered, a mode of treatment oftentimes found bénéficiai 
where delirium cornes on suddenly, in the course of another disease, in persons 
habituaJly addicted to ardent spirits. The resuit was favôurable; the patient 
obtained calm sleep, from which he awoke with his intelligence quite perfect. 
Ail fever also disappeared ; he now seemed convalescent. Again, however, 
without any known cause, the delirium and fever returned, and an opiate was 
again employed ; but whether from its being given in too small a dose, or that the 
functional disturbance was now beyond the reach of opium, the cérébral symptoms 
continued to become worse, and, seven days after their re-appearance, the patient 
died. 

It was not probably during thèse seven days that the morbid altérations in the 
méninges were formed. The pia mater had certainly been the seat of inflamma- 
tion. Was it so, when the delirium ceased so readily after the first opiate was 
given ? We know that opium lias, under ordinary circumstances, the property of 
exciting cérébral congestion, or, at least, that it produces symptoms which are 
accounted for by such congestion. We know nothing positive regarding the 
nature of the lésion existing in the brain, or its membranes, on the first appearanec 
of the delirium ; nor is it necessary to believe, that congestion is necessary to 
produce such a symptom ; as we know from the -post mortem examinations of 
several who, during life, had the same symptoms as this individual, and yet no 
lésion was found to account for them. We think, that in such cases, there 
supervenes, in the nervous substance, a modification, whose anatomical sign 
escapes us, which précèdes either the congestion, or the other altérations, which 
constitute the anatomical characters of encephalitis or meningitis. May not 
opium, which is mischievous when once the congestion is established, be then 
administered, inasmuch as, the brain not being in its normal state, the opium loses 
the power of producing congestion in it ? We think it likely that, if the opium 
had been administered the second time in as large a dose as at first, on the 
re-appearance of the delirium, it w r ould have again succeeded in removing the 
nervous symptoms. 

Case 13, — Serons kyst developed in the pia muter — Great quantity of turbhl sérum 
in this membrane — Hemiplegia at the âge of eight years, which completely disap- 
peared at puberty — Atrophy and debïlity of the limbs formerly paralysed — 
Cancerous ulcer of the stomach. 
This was the case of a man seventy-two years old, who, at the âge of eight 
years, was struck with paralysis of the limbs of the left side, which remained tilî 
puberty, and then gradually disappeared ; thèse limbs continued, for the remainder 
of his life, much less developed and feebler than those of the opposite side. He 
also usually experienced in them a sensation of cold. For the last four years of his 
life his digestion became very much deranged, and he lost ail appetite, and without 
any pain of head or any other part, he gradually wasted away, and died in a state 
of extrême emaciation. 

Post mortem. — The sub-arachnoid cellular tissue of the convexity of the hémi- 
sphères was infiltrated with a considérable quantity of turbid sérum, and on 
removing the membranes, the circumvolutions of the two hémisphères appeared 
farther separated than ordinary, by the great quantity of fluid filling up their 
anfractuosities. Near the great interlobular fissure, towards the middle part of 
the right hémisphère, there was found in the midst of the sub-arachnoid cellular 



1G 



CLINIQUE MÉDICALE. 



tissue, a serous cyst, about the size of a small apple, which depressed the cérébral 
substance beneath it. An enormous quantity of frothy colourless sérum flowed 
from the right lung when eut into. The mucous membrane of the stomach 
presented, at the distance of about three fingers' breadth from the pylorus, a 
rounded ulcer, about five inches in diameter, the edges of which, formed of 
mucous membrane, were of a livid red coîour. In two or three places the parietes 
of the stomach were perforated by this ulcer, and the pancréas was exposed. 

Remarks. — The serous kyst developed in the pia mater, was here no doubt 
the resuit of the lésion which had been in his early life the cause of the hemiplegia 
in this individual. There was no disturbance of the intelligence observed at any 
period of the patient's life, which circumstance may be accounted for by the slow 
manner in which the effusion took place *. 



CHAPTER II. 

DISEASES OF THE MENINGES OF THE LOWER SURFACE OF THE BRAIN. 

Case 15. — Purulent infiltration of the pia mater covering the lower surface of the 
brain — Turbid sérum in the inferior occipital fosses — Delirium at the commencement 
of the disease ; subsequently profound coma — Pulmonary tubercles. 
A tailor, twenty-seven years old, had been for three weeks in the hospital, with 
ail the symptoms of advanced phthisis, when one morning we were struck with 
the indistinetness of his answers; in fact, he seemed as if drunk. The pupils 
were strongly contracted, and there was great fébrile disturbance ; on the follow- 
ing morning he presented the following state : head turned backwards, nor could 
it be brought forward, without eliciting screams from the patient ; pupils very 
much contracted ; makes no answers ; occasionally raves ; sorne froth at the 
mouth ; teeth closed as in trismus ; puise more than one hundred and twenty ; 
skin hot (two blisters to the legs). For the four following days the ré- 
troversion of the head, and the closing of the jaws, disappeared ; the tw r o 
pupils remained contracted ; on raising the eyelid, we thought the sight quite 
gone ; he seemed plunged in a profound sleep, scarcely drew back his limbs 
when pinched. Puise now but of moderate frequency; skin not very hot, was 
aîmost constantly covered with abundant perspiration. The tongue never changed 
from its natural appearance. The coma however became more and more pro- 
found ; the respiration became embarrassed, and the patient expired as in a state 
of apoplexy. 

Post mortem. — We found the entire lower surface of the cérébral hémisphères 
covered by a thick layer of concrète pus contained in the pia mater; it was found 
in great quantity, particularly in the fissure of Sylvius, and around the thalamus of 
the optic nerves. Five ounces at least of milky sérum were effused between the 
cranium and lower surfaces of the cerebellum. Numerous tubercles in différent 
states existed in the lungs. 

* The fourteenth case given by Andral resembled the above very much, with respect to 
the anatomical lésions found in the encephalon, except that instead of one, there were several 
kysts discovered. Yet the symptoms differed considerably, the intelligence being the function 
disturbed in the latter case, whilst the power of motion was affected in the other. May this 
diversity of symptoms, he asks, be explained by the différence in the intensity of the pressure 
to which the brain was subjected in the two cases ? — T. 



DISEASES OF THE ENCEPHALON. 



17 



Remarks. — One could not have announced ïrom the symptoms during life, that 
the membranes at the base of the brain were the exclusive seat of the disease, as 
nearly similar symptoms were observed to exist in cases where the méninges of 
the upper surface were engaged. MM. Parent du Chatelet, and Martinet have 
given coma as the distinguishing characteristic of meningitis of the base. But 
this symptom has been observed in cases where the méninges of the convexity 
were affected. The absence of headach could not be accounted for by the 
seat of the affection, as the same absence was observed where the membrane of 
the convexity was the seat of inflammation. Neither can the contraction of the 
pupils be converted into a sign, as in diseases precisely similar, both in their seat 
and apparent nature, the pupils have been observed sometimes considerably 
dilated, sometimes strongly contracted, and sometimes in the natural state ; and 
occasionally contracted on one side and dilated on the other. Acute meningitis 
is very rarely observed to accelerate the death of phthisical patients. Some of 
them, to be sure, become delirious a little before death ; but no lésion of the brain 
or its membranes has been detected to account for this symptom. 

Case 16. — Intense headache with vomiting at first — Tendency to sleep, and disin- 
clination to move — Graduai establishment of coma — Natural state of the pupils — 
Purulent infiltration of the pia mater of the base of the cerebrum and cerebellum. 
A labouring man, of middle âge and strong constitution, on entering the hospitaî 
complained of nothing but violent headach, which commenced five or six days 
previous, and was for the first two days accompanied with a painful vomiting. 
The temples were the seat of the pain ; they seemed as if compressed in a vice ; 
at intervais he felt acute lancinating pains either at the temples or the occiput, and 
occasionally the back of the neck became so painful that the patient could not 
move : he then presented ail the symptoms of wry-neck — he felt easy only when 
perfectly at rest; appetite gone ; and w.hat he ate, he said, gave him no strength ; 
since the invasion of the headach had been but once at stool. We saw him 
first on the 3rd of July, when he presented the following state : — Face pale and 
dejected ; look quite vaeant ; eyes very sensible to strong light ; intelligence clear ; 
puise and skin natural. The headache the only important symptom in this case ; 
(bleeding to sixteen ounces ; sinapisme to legs ; purgative lavement) ; the blood 
formed into a soft coagulum, with little sérum, and no buff 4th Julv He 
complained aloud of the violent pain of head ; he fancied his skull oeaten in as it 
were with a hammer. Still his forehead was çool, and his face paler than the day 
before ; the pupils, intellect, circulation, natural. Thus the bleeding produced no 
diminution of the headach. — (a second bleeding). On the 5th thirty leeches were 
applied to the neck. On the 6th headach less ; but he answers questions with 
difficulty ; he lies on his back and remains motionless, and resembles a person 
going to sleep, or whose eyelids are struggling against sleep. He still retains his 
intelligence, but appears to use it in spite of him ; countenance very pale ; features 
drawn, and as it were fatigued. (Two blisters to the legs.) On the 7th he ap- 
pears in a profound sleep, will not answer questions ; when bid he puts out his 
tongue readily, which still remains white and moist. On being pinched he shows 
that he still retains ail his sensibility ; pupils sensible to light ; puise sixty ; heat 
of skin natural. 8th and 9th. Profound coma ; he refuses to open his eyes, and 
appears not to hear the questions put to him ; pupils natur-al ; some sensibility still 
retained (strong sinapisms to the lower extremities). On the lOth. Coma still; 
complète loss of sensibility ; yet, notwithstanding this annihilation of the fonc- 
tions of relative life described by the ancients under the name of lethargy, the 
functions of organic life still perfect; puise, température of skin, and respiration, 
natural. On the 12th, for the first time, the respiration appeared affected; some- 
times very much accelerated, at other times so slow that the respiratory movement 
just made, seemed not likely to be succeedecl by another. On the 13th. Respi- 



18 



CLINIQUE MÉDICALE. 



ration still accelerated ; in the course of the day the trachéal raie set in, and the 
patient died in the night. 

Post mortem. — The upper part of brain and méninges being minutely examined, 
no morbid appearance was detected ; but on examining the lower surface, the 
pia mater covering it was infiltrated with a purulent layer from seven to eight 
lines thick. 

Chest. — Lungs very much engorged, as the lungs of apoplectic patients, or of 
animais who die a certain time after a division of the pneumo-gastvic nerves ; 
the right cavities of the heart distended with clots of considérable consistence ; the 
left cavities empty. 

Remarks. — In this case and in the precedîng the lésions found in the dead 
body were similar, and had the same seat ; yet, how différent were the symptoms 
in both cases ! In the latter case, the seat of the headach was far removed from 
the place where the autopsy detected the lésion. The several bleedings seemed 
to exercise no influence on the pain ofthe head ; a little after them, the patient, 
without any previous disturbance of intellect, fell into a state of coma, which became 
every day more and more profound. Up to the end the puise continued natural, 
and it was only towards the termination that the respiration became disturbed, 
and death seemed the immédiate resuit of the disturbance of this function. The 
slight disturbance of digestion was but sympathetic. The vomiting, which showed 
itself at the same time as the pain of head, seemed of the same nature as that 
which so frequently accompanies the acute hydrocephalus of children, depending 
equally on disturbance of the nervous centres. The constipation observed in this 
case is an ordinary symptom when the brain is afFected. 



CHAPTER III. 

DJSEASES OF THE MENINGES COVERING THE PARÎETES OF THE VENTRICLES OF 

THE BRAIN. 

The cellulo-vascular web extended over the parietes of the latéral ventricles 
is not visible in the natural state, but becomes so from the effects of disease. 
Over thèse parietes may be observed at times large veins filled with blood. We 
thought this venous engorgement coincided pretty often with a greater or less 
collection of limpid sérum in the cavities of the ventricles. We never observed 
on the surface of the parietes of thèse cavities a fine injection similar to that which 
appears often on the pia mater around the brain. In more than one case we found, 
in the interior of the ventricles, either limpid sérum in great quantity, or even 
a milkyfluid, pus, membranous flocculi, like those of the peritoneum and pleurœ ; 
and in those différent cases where there existed within the ventricles so remark- 
able an altération in the sécrétion, the membrane furnishing the morbid product 
did not itself présent any appréciable altération. Thèse ventricular meningeal in- 
flammations are very seldom found to exist separate ; they most frequently co- 
exist with meningitis of the base or convexity of the brain, and their symptoms 
are confounded with those produced by inflammation of the méninges of the other 
parts of the encephalon. The following cases may be interesting as rather 
uncommon instances of isolated ventricular meningitis. 

Case 17. — Sero-purulent effusion into the cérébral ventricles — Cystitk — Violent pain 
ofhead at the commencement, afterwards delirium, coma, tongue dry, rétention of 
urine. 

A man, twenty-nine years old, a saltpetre maker, residing in Paris for the last 



DISEASES OF THE ÉNCEPHALOK 



19 



ei^ht months, generally enjoying good health, and regular in his habits, awoke on 
the morning of the 21st December with a violent headach, feeling of lassitude, 
achinsr of the limbs and anorexia. This state of gênerai uneasiness continued 
durins: the following days. He still continued to work till the 27th, when, feeling 
himself becoming ïeebîer, he kept his bed. On the 31st he entered the La 
i r hen he présentée! the following state : — 

Countenance pale, features drawn, and as if harassed, eyelids weighed down, 
air of stupor ; violent pain of head, particularly at the forehead, and extending 
soraetimes to the rest of the head ; power of motion free ; muscular strength still 
considérable ; tongue red and dry ; some thirst : disgust for every kind of food ; 
slight pain in the epigastrium, constipation, puise fréquent and tolerably full, skin 
hot and dry, tumor in the hypogastric région formed by the bladder distended 
■with urine. — (blood-letting, blister to one leg, purgative lavement \ On the follow- 
ing day the state of the patient the same ; no stool ; the blood drawn presented a 
soft coagmlum without buff. On the 3rd. prostration, and air of stupor increased ; 
answers slow and difficult ; constantly complains of headach ; paralysis of blad- 
der continued, which rendered the fréquent introduction of the cathéter necessary ; 
tonzue moist : pressing on abdomen caused pain, which might dépend on the 
distension of bladder ; still constipation ; puise still fréquent and full (sixteen 
leeches to neck, twelve grains of Dover's powder, purgative lavement). On the 
4th, no amendment ; skin still dry ; tongue red, and again becoming dry ; the 
lavement had no effect : bladder very macfa distended (leeches again, and Dover's 
powder, lemonade, with a little wine added). 

On the evening of the ôth became délirions, and on the following moraing he 
uttered constant complainte; he said he no longer had pain of head; stupor more 
marked ; tongue red and dry ; one stool ; urine very abundant, and still drawn off by 
the cathéter. On the 7th. Acute pain of head; tongue quite dry; puise fréquent, 
and of considérable strength ; skin dry and hot ; thirst ; deliiïum. On the 8th. 
Profound coma ; eyes closed ; mouth half open ; answered no questions ; feit pain 
when abdomen was pressed ; when the skin of one of the extremities was pinched 
he drew it back, and face assumed an expression of pain. The two arms, when 
raised, feH back as inert masses; respiration occasionally high and hurried; then 
became slow, and the respiratory movements succeeded each other at long 
intervais. The respiratory murmur not blended with any raie, and its intensity 
in proportion to the considérable raising of the thoracic parietes. Puise one 
hundred and twenty, and the intervais of the pulsations unequal. Some subsultus 
in the tendons of the muscles of the fore-arm ; great quantity of urine. In the 
course of the day the intermissions of the respiration became more and more con- 
sidérable : at last it stopped altogether, and the patient expired. 

Post mortem.— Several veins in the subarachnoid cellular tissue of the convexity 
of the hémisphères gorged with blood. On making an incision into the upper 
wall of each latéral ventricle, an immense quantity of milky sérum rlowed out, in 
which some albuminous floculi fioated. On slightly touching the internai wall of 
each of the ventricles, from the ancyroid cavity to the anterior extremity of their 
inferior portion, the cérébral substance was found very soft for the space of one or 
two lines.. and. seemed as it were diffluent under the fmger. 

Thorax. — Nothing particular. 

Abdomen. — A great quantity of liquids distended the stomach. We observed on 
its inner surface two red spots, one the size of a five-sous pièce, and the other 
that of a twenty-sous pièce. In the large intestine, veins were seen in considéra- 
ble numbers in the mucous membrane of the caecum. The mucous membrane of 
the bladder exhibited a bright red injection in its entire extent ; and in several 
parts it was covered with a purulent exudation. 

BemorJcs. — This case resembled in many points, with respect to the symptoms, 
certain cases of tvphoid fevers, to be recorded in another portion of this work, 

c 2 



20 



CLINIQUE MÉDICALE. 



The tongue, which we found in its natural state in the cases preceding tins, here 
presented that redness and dryness so common in dothinenterite ; the countenance 
also presented that air of stupor so characteristic of exanthematous inflammation 
of the small intestine. There was no other cérébral symptom, properly speaking, 
except the delirium folio vved by profound coma, and even those two symptoms 
appeared only during the last two davs. Puise was constantly fréquent, and the 
skin presented that dryness so often accompanying acute inflammation of the in- 
testinal follicles, to w'hich part, in fact, one would for many reasons be inclined to 
refer the seat of the disease, and the cause of the continued fever. Yet the post 
mortem disproved this ; what we found being a sero-purulent effusion into the 
latéral ventricles, with a superficiel softening of the cérébral substance of a portion 
of their parietes. We also found remarkable lésions in the bladder, its mucous 
membrane being every where red, and a purulent layer covering it. Was then 
the rétention of the urine in this case connected with cystitis ? or was the latter 
the resuit of the repeated introduction of the cathéter ? If we now recur to the 
commencement of the disease, we shall find that it began with headach, a symp- 
tom, the fréquent, though not necessary existence of which we have also observed 
in meningitis of the base, as well as in that of the convexity of the cérébral 
hémisphères. This having been the first symptom, we had certainly some reason 
for suspecting the brain or its membranes to be the part affected, yet we could 
not have been certain of it, particularly when we recollect pain of head similar 
to this, to have ushered in and accompanied as the leading symptom, différent 
cases of dothinenterite. Shall we take into account, in order to establish our 
diagnosis, the remarkable state of the respiration towards the close ? Frank, in 
fact, has given, as one of the characteristic signs of encephalitis, those long inter- 
missions of the respiration ; in this disease, he says, the patient respires deeply, 
and at long intervais : Spiratio magna ex longis intervallis ducitur. But the same 
state of the respiration has been found in several cases of dothinenterite, without 
any appréciable lésion of the brain after death. 

Case 18. — Sero-purulent effusion into the latéral ventricles — Granular appearance of 
the membrane Uning their parietes — Alternation of delirium and coma ; of stupor and 
violent agitation; of abolition of muscular contractions, and st? , o?ig tétanie twitche s — 
Puise occasionally rare and fréquent. 

A lapidary, twenty-one years of âge, was admitted into the la Charité, on the 
20th of April, 1820. What particularly struck us then, was his air of déjection ; 
he kept his head under the bed-clothes, and refused to answer questions ; he 
merely told us that, for several days, he had over the entire abdomen, pains which 
were not increased by pressure, and that for a considérable time he had had no 
stool ; puise not fréquent. The nature of the abdominal pains, the constipation and 
apyrexia, together with the circumstance of his being a lapidary, caused us to 
suspect lead colic. The ordinary treatment of the hospital for this affection was 
accordingly adopted. 

On the 21st, skin hot; puise fréquent; the treatment of the preceding day dis- 
continued. Diluent drinks prescribed. 

From 21st to 26th, the fever continued; the air of sadness still remains ; 
slight abdominal pains ; constipation still ; tongue natural (drinks continued ; 
purgative lavement; linseed cataplasms over the abdomen). 

On the 26th, patient lay on his back, his look being fixed ; the two pupils a 
little contracted, the right less than the left; head somewhat turned back. He 
refused to answer questions, and talked incoherently ; several times in the nîght 
he attempted to escape out of bed, so that restraint became necessary. Tongue 
natural ; puise fréquent (two blisters to the legs). 

On the morning of 27th, profound stupor ; patient perforais no motion whatever ; 
abdominal pressure gives no pain ; puise lost its frequency ; beat of skin no longer 



DISEASES OF THE ENCEPHALON. 



■21 



raised ; constipation still continues. — (eight leeches behind eachear; two blisters 
to the thighs ; minerai lemonade). 

On the 28th, comatose state quite gone ; he puts out his tongue when asked, 
but gives no other signs of intelligence ; utters not a word ; pupils a little dilated ; 
tongue natural ; no stool ; apyrcxia (purgative lavement, &c). 

29th, No change ; but on the 30th agitation and delirium, as on the 26th ; con- 
stantly rubbing his hands together ; belly tympanitic ; puise not fréquent ; tongue 
moist and pale (twenty leeches to neck ; twelve grains of calomel). 

lst May, delirium continues; rétroversion of the head ; carphology ; pupils 
dilated ; puise very fréquent ; abdomen tympanitic (twelve grains of calomel ; 
frictions to the abdomen, with linim. ammon. camphor., and aromatic fomentations 
to the same part). 

2d May, delirium continues, as also the carphology ; continuai tossing of the 
head alternateîy from right to ieft, and vice versa; moaning ; sudden shoeks of 
the trunk and limbs, like those of tetanus ; carotids beat strongly ; the heart raises 
the parietes of the thorax; tympanitis considérable. Death at eight o'clock at 
night, after discharging a considérable quantity of blood from the nose and mouth. 

Post mortem. On a level with the centrum ovale of Vieussens, on each side of 
the corpus callosum, we perceive a manifest fluctuation ; an incision made into 
the latéral parts gave exit to a considérable quantity of liquid, like whey 
not ciarified, in the middle of which albuminous shreds are seen to float. From 
the surface of the parietes of each ventricle, a very thin membrane is detached, 
which is traversed by very minute vessels curiously injected. On some points of 
the free surface of this membrane, small greyish bodies exist, the size of a pin's 
head, like the rudiments of false membranes, which, under the form of granulations, 
are sometimes scattered over the peritoneum. 

TJiorax. The pleura costalis and pulmonalis adhère by well organised cellular 
tissue. The lung of this side contained a great number of tubercles, principally 
miliary, some were larger, and softened. The bronchi of this lung were very red, and 
the bronchial ganglia hard and black. The left lung also adhered to the pleura, 
but contained not a trace of tubercle. The two serous folds of the pericardium 
were internally united to each other by a false membrane several lines in thick- 
ness. 

Abdomen. The anterior wall of this cavity prqjected considerably before the 
thorax ; when struck, it sounded like a drum. The intestines were enormously 
distended with gas ; stomach contained a great quantity of mucus, and the small 
intestine a great quantity of bile. In the cœcum and colon, ascending as well as 
transverse, the mucous membrane was very much injected. The left lumbar colon, 
filled with very hard fsecal matter, was white on its internai surface, as was the 
sigmoid flexure and the rectum ; above this last intestine was a very marked 
circular contraction. The gases and fœces accumulated in the colon could with 
difficulty get through it ; rectum empty. 

Remaries. — In this patient the nervous symptoms were much more marked and 
varied than in the preceding. In both the cérébral lésion was of the same nature, 
and had the same seat. In the latter case, as in the former, the lésion discover* 
able by anatomy existed only in the latéral ventricles. With this inflammation of 
the ventricular membrane coincided différent symptoms, some of which are gene- 
rally regarded as characterising meningitis of the convexity of the hémisphères, 
and others more especially connected with meningitis of the base ; thus on the 
one hand there was delirium and fréquent tossing, on the other a state of coma. 
We often see thèse two orders of symptoms replace each other, and at the same 
time there are observed very remarkable disturbances in the muscular contraction, 
characterised by shocks of the trunk and limbs like those of tetanus, and a forcible 
reversion of the head. If we refer to the period when we fîrst saw the case, we 
shall again find some phenomena worthy of remark, connected with the nervous 



22 



CLINIQUE MÉDICALE. 



System. The profound sadness of the patient then, that air of déjection, and dis- 
position to conceai his head under the bed clothes, as if to avoid our look and 
questions, his .reluetance to answer, &e., were certain indications of a commencing 
cérébral affection. This state of the patient prevented us, unfortunately, from 
procuring an} 7 information as to what he had suffered before he came to the 
hospital— as, for instance, whether he had had pain of head. The tongue was 
constantly natural ; not so in the preceding case ; and yet the primes via? were 
here affe.cted ; for at différent times, and especially on entering the hospital, he 
complained of acute pain in the abdomen, and had most obstinate constipation. 
Had he the beginning of lead colic ? We must not lose sight of the bright red 
appearance found in a great portion of the large intestine, and the accumulation 
of faeces in the sigmoid flexure, which a circular contraction of the commencement 
of the rectum prevented from passing into the latter intestine. This contraction 
depended on no organic lésion ; it appeared to be the resuit of a spasmodic affec- 
tion of the muscular coat. 

Case 19. — Serous effusion into cérébral ventricles—Pain of head at the commence- . 

ment — Subsequently coma — Accélération of the puise some hours only before death. 

A mason, twenty-three years of âge, had been complaining for several days of 
violent pain of head, when he entered the hospital. Tongue white ; puise not 
fréquent ; no other ailment than the headach. Two grains of tartar emetic were 
given him. He vomited twice very copiously, and had two stools. The following 
day the state of the patient underwent a remarkable change. His intelligence 
very much diminished ; he answered questions slowly and with difficulty. Still 
complained of the headach ; puise and tongue natural. (Twelve leeches behind 
each ear.) 

On the 17th. Great stupor. On being very much solicited. he opened his 
eyes slowly, and looked around him with the most vacant stare. On being asked 
how he found himself, he answered, that he was doing very well. Pupils did not 
contract on the approach of a very strong light ; they were not much dilated, the 
rïght a îittle less so than the left. State of puise and skin natural. (Six leeches 
to each mastoid process ; a pint of whey, with the addition of a grain of tartar 
emetic, and four drachms of sulphate of soda; two blisters to the thighs ; frictions 
with linim : volât : cantharid : to the extremities.) 18th. Stupor continues ; 
utters some unmeaning words; puts out his tongue when asked; pupils more 
dilated than on the preceding day, and equally so ; puise has acquired some 
frequency ; tongue dry ; bladder very much distended. — (a pint of whey, with a 
grain of tartar emetic, and an ounce of sulphate of soda; frictions with linim. 
ammon.). During the day the coma increased, and he died during the night. 

Post mortem. — The two latéral ventricles were found to be very much distended 
with limpid sérum ; some was also found in the third ventricle. Nothing remark- 
able was observed in the other cavities. 

Remarks. — The symptoms here did not differ much from those in the seventeenth 
and eighteenth cases, in which pus was found to fill the ventricles. There was no 
fébrile excitement at ail in the course of the disease, and it was only a few hours 
before death that the puise became accelerated. 

Case 20. — Copious serous effusion into the latéral ventricles — Destruction of. the 
fornix and septum lucidum — Symptoms of apoplexy. 
A man, fifty years of âge, entered the La Charité with considérable anasarca 
and ascites ; no local sign of organic disease of the heart ; respiration free ; states 
that he never felt any pain m the right hypochondrium ; the dropsical effusion 
took place three months previously, but we could not learn from him where it 
commenced ; digestion well performed ; no new symptom presented for the fifteen 
days following. One morning, on approaching his bed, we found him in a state 



DISEASES OF THE ENCEPHALON. 



23 



of apoplexy, totally deprived of consciousness. We were told that since the even- 
ing before he had not spoken : face pale ; eyes appeared deprived of sight ; both 
pupils sensibly dilated ; the extremities when raised fall as inert masses ; total 
insensibility ; puise not fréquent ; respiration hurried and stertorous ; trachéal 
raie very loud. He died some hours after the visit. 

Postmortem. — Considérable serous infiltration of the upper and lower extremities. 

Cranium. — A small quantity of limpid sérum infiltrâtes the subarachnoid cellular 
tissue of the convexity of the brain. The two latéral ventricles were confounded 
with the third into one enormous cavity, from which there flowed two glasses 
full, at least, of sérum clear as spfing water. In the place of the septum lucidum 
and fornix, there was nothing but small fragments of a white pulp floating amidst 
the sérum. 

Thorax. — Lungs very much engorged ; in other respects sound. In the heart, 
which was natural in every respect, and in the rest of the arterial System, there 
was found but a very small quantity of blood, remarkably liquid. Some liquid 
blood, and that in small quantity, was ail that was found in the veins. 

Abdomen. — The peritoneum contained several pints of limpid sérum. The liver, 
which was of the ordinary size, was remarkable for its great hardness — as also the 
spleen. 

Remaries. — Here again we have a considérable effusion of sérum into the ven- 
tricles, together with a breaking down of the central white parts of the brain. 
We are disposed to considerthe destruction of the septum lucidum and the fornix 
as the mechanical resuit of the pressure made on them by the fluid in each ven- 
tricle. In the two cases preceding we have seen, notwithstanding the identity of 
the lésions found after death, that the symptoms were far from being similar. 
Here again we have the same lésions, and the symptoms were those of apoplexy, 
that species of it usually called serous apoplexy. Dropsy, of which the cause was 
obscure, was the only disease the patient laboured under ap to the apoplectic 
attack ; and, to account for tins dropsy, we found no other lésion, except the 
morbid state of the liver. There existed already then, in this individual, a dispo- 
sition of long standing to serous effusions ; when suddenly, no doubt, the serous 
membrane, lining the cérébral ventricles, exhaled a large quantity of sérum, wliich 
caused ail the symptoms of real apoplexy. Thus we have sometimes seen in 
dropsical patients great dyspnœa suddenly supervene, and death follow after some 
hours the constantly increasing difficulty of respiration. It was accounted for by 
a serous effusion which took place ail at once into both pleurse. In the présent 
case the anasarca and aspites did not diminish when the effusion into the cérébral 
ventricles took place. In another individual, whose history shall be given else- 
where, both the anasarca and ascites were considerably diminished before the 
appearance of the apoplectic symptoms, which, as in the présent case, were pro- 
duced by a sudden effusion of sérum into the cérébral ventricles*. 

Case 21. — Considérable serous effusion into the latéral ventricles, with destruction of 
the septum lucidum and of part of the fornix — Ossification of the great faix 
Cerebri — Symptoms of apoplexy. 

A man, seventy-two years of âge, entered the La Charité during the month of 
Dec. 1821. He had been for a long time labouring under pulmonary catarrh ; 

* A case sornewhat similar occurred in Dublin, about tbree years since, under my own 
care. It was that of a man of very intemperate habits, whose liver was considerably 
enlarged ; he had ascites and anasarca, and was treated in the usual way, without any 
amendrnent. One morning, when he awoke, he found the size of the abdomen very muen 
diminished, and the swelling of the lower extremities quite gone. He arose from bed at 
twelve o'clock in the day, sat a few hours at the fire, became drowsy, threw himself on the 
bed, and when his wife went to call him, at about four o'clock in the evening, she found hirn 
dead. The ventricles of the brain were found to be enormously distended with limpid sérum. — T. 



24 



CLINIQUE MÉDICALE. 



for the last two months he kept his bed, being very much debilitated. When we 
saw him, he had some fever ; tondue dry and brownish red ; a little cough in very 
distressing kinks, accompanied witri the expectoration of puriform mucus ; intelli- 
gence perfect. He was ordered pectoral drinks, which he continued to use for 
fifteen days, when suddenly he lost ail consciousness ; his eyes closed ; the four 
extremities lost the faculties of sensation and motion ; sensibility gone ; on raising 
the eye-lids we might touch the conjunctiva without his feeling pain ; the pupils 
were dilated and immoveable ; the puise retained some strength and considérable 
hardness, but had lost its frequency ; the skin was covered with a copious sweat ; 
each inspiratory movement was accompanied with a loud trachéal raie. Death 
took place the following night. 

Post mortem — Cranium. — More than an ordinary glass full of water filled both 
latéral ventricles ; no trace of the septum ; in place of the middle part of the 
fornix, we found a white pulp, which was raised with the scalpel from the upper 
surface of the choroid plexus. The great faix cerebri ossified. 

Thorax. — Considérable infarction of the lungs. On cutting into them, a consi- 
dérable quantity of frothy, colourless sérum flowed from their tissue. Slight 
hypertrophy of the parietes of the left ventricle ; numerous incrustations on the 
inner membrane of the aorta. 

Abdomen. — A viscid mucous covers in considérable quantity the inner surface of 
the stomach ; beneath it a bright injection of its mucous membrane towards the 
great cul de sac, as also of the small intestine. 

Remaries. — This is a well-marked case of what is called serous apoplexy coming 
on in an old man, exhausted by chronic irritation of the gastro-pulmonary mucous 
membrane. In this, as in the preceding case, the patient lived but a few hours 
after the first symptoms of apoplexy, during which the puise retained its hardness, 
but became very slow ; the slowness depending on the serous effusion into the 
ventricles of the brain, and the hardness of the puise on the commencing hyper- 
trophy of the parietes of the left ventricle. 

Case 22. — Sangui?ieons congestions in the brain, terminating in sei'ous effusion into 
the latéral ventricles. 

A woman, fifty-one years old, of a sanguine tempérament and strong constitu- 
tion, ceased to menstruate about her forty-ninth year ; during the six months fol- 
lowing she was subject to a numbness in the right. arm. In her fifty-first year she 
suddenly lost consciousness, fell, and retained, when she came to herself, some 
difficulty in her speech, with some falling of the commissure of the lips and tongue 
on the right side, considérable diminution of motion and sensation on this side, 
nausea and bilious vomiting. Under proper treatment this state disappeared at 
the end of four weeks. After this the patient returned to a perfect state of health, 
when, towards the middle of March, 1819, she again began to feel a little w 7 eak- 
ness in the right arm ; slight pains of head in the frontal région soon supervened, 
and, on the 26th of April, without any obvious cause, there came on in the night, 
during sleep, a new attack, more violent than the former, and of the same side ; 
total loss of speech ; considérable diminution of sensation, but particularly of 
motion, in the extremities of the right side ; features not altered ; tongue fell a 
little on the right side. This new attack disappeared, however, more promptly 
than the preceding, and at the end of three days, the patient having entered the 
hospital, presented the following state : — She had slept well the previous night; 
some weight of head ; tongue unsteady when she puts it oufe ; some numbness and 
weakness on the right side of the body ; speaks distinctly ; puise full, strong, and 
slow ; habituai constipation (lemonade with cream of tartar ; fifteen leeches to 
each foot ; warm pediluvium ; purgat. lavement). In the morning she took some 
soup, and was seized with vomiting in the course of the day, when she threw up 



DISEASES OF THE ENCEPHALON. 



25 



some bile. The vomiting brought on a new attack, followed by an increase of 
the hemiplegia on the right side and greater embarrassaient of speech. She was 
bled to ten ounces. New attacks of a slight nature appeared in the night, upon 
which sinapisms were applied to the feet : after this the fœces passed involuntarily. 
On the 30th, hemiplegia more developed ; articulation nearly impossible ; puise 
less full, less hard, and more accelerated ; paralysis of the bladder (lemonade 
with one ounce of soluble tartar ; bleeding from the jugular vein ; purgative lave- 
ments ; introduction of the cathéter). Immediately after the bleeding (ten 
ounces) a new attack, followed by total loss of speech, and of motion in the right 
extremities ; frothing at the mouth ; dilatation of the pupils ; countenance quite 
vacant. On the following morning thèse symptoms were ail aggravated ; trismus 
also supervened, which prevented her from drinking, and constant drowsiness. 
On the lst of May, pupils immoveable, blindness, trismus, frothing at the mouth 
at each expiration,; contractility abolished on the right side, almost none on the 
left ; a little sensibility on both sides, rather more on the left ; puise full, hard, 
irregular for the number of pulsations (twenty leeches to the neck ; blister to 
legs ; purg. lavements). She died a little after the visit. 

Post mortem — Cranium. — The latéral ventricles contained nearly four ounces 
of limpid sérum ; no lésion in the thoracic or abdominal viscera. 

Remarks. — The apoplectic attacks in this case seem to have been produced by 
simple sanguineous congestions in the brain. It would appear that here the hemi- 
plegia was the resuit of a sanguineous congestion greater in one hémisphère than 
in the other, whereby this hémisphère lost its influence over the muscular con- 
tractility, even when the congestion ceased to exist. The first time the hemi- 
plegia was preceded by a total loss of consciousness ; the second time it was 
graduai, and not announced by any symptom of apoplectic attack. The more 
alarming symptoms observed for the last two days were the resuit of the serous 
effusion into the ventricles, of which the habituai sanguineous congestions had 
been probabîy a predisposiug cause. We should not forget to notice here the in- 
fluence of the vomiting on increasing the hemiplegia. 



CHAPTER IV. 

CASES WHEREIN THE ENTIRE OF THE MENINGES WERE INVOLVED. 

Case 23. — A man, fifty years of âge, naturally of a strong constitution, 
having been very unsuccessful in his commercial spéculations, came to Paris, 
where, after residing for some time, he became affected with gênerai debility, 
which went on daily increasing. At last he entered the La Charité on the 
llth Nov. 1821. During the first two or three days he scarcely appeared 
ill in any way ; but was plunged into a profound melancholy. On the 15th, 
he complained of total aversion to food ; his tongue was covered with a thick 
yellow coat ; abdomen free from pain ; no fever. During the day he took 
twelve grains of ipecac. and vomited abundantly. On the following day he 
seemed better. On the 17th, however, the puise had become fréquent; 
tongue showed a tendency to become dry ; he vomited his drinks ; his bladder, 
distended with urine, formed a tumour above the pubis ; he explained his state 
perfectly ; he was still more sad and taciturn than usual (the urine was drawn 
off ; linseed lavements). 18th. Same state of bladder ; countenance exhibits great 
stupor ; still the intellectuel and sensoriai faculties unimpaired ; patient complains 
only of great debility ; tongue moist and foui ; no stool ; puise scarcely fréquent ; 
skin not bot. — (lavement of marsh-mallow with a scruple of camphor ; frictions on 



CLINIQUE MÉDICALE. 



the extremities with linim. volât, cantharid.). 19th. In the same state. 20th 
Prostration greater ; lie lies on his back quite motionless, with his eyes turned up 
and fixed ; he appeared indiffèrent to every thiog passing around him ; answers 
questions precisely, but slowly ; puise fréquent ; skin hot ; tongue still moist 
(six leeches to the anus ; eamphor lavement, lemonade). On the 21st, for the 
flrst time, he complained of headach, without being able to point out its précise 
seafc ; though he answered questions, still his mind was disturbed at intervais ; 
his eyes were constantly directed towards the roof of the bed, except when he was 
spoken to ; tongue, which was very yellow, again showed a tendency to become 
dry ; abdomen was tympanitic, and since the preceding day the fœces passed in- 
voluntarily — they were liquid ; puise very fréquent and compressible (four 
leeches behind each ear ; fomentation with camphorated oil of camom. to the abdo- 
men ; sinapisms to the lower extremities ; infus. quînquin. &c.) In the course of 
the day the fœces passed involuntarily twice ; raved ail the night. On the 22d, 
stupor more marked ; eyes, which were directed towards the roof of the bed, 
were occasionally closed ; mouth half open ; no answer could be elicited from 
him ; tongue very dry, and a dark yellow ; abdomen again soft ; on pressing it 
strongly the respiration was very much accelerated ; puise ninety-eight, very 
small, and very irregular ; the skin covered with an abundant sweat. On the 28d. 
eyes dull, features quite altered ; puise one hundred, and thready ; skin still hot 
and moist ; passed no urine for the last twenty-four hours. He died in the course 
of the day. 

Post mortem forty-six hours after death — Cranium. — Considérable injection of the 
membranes over the entire convexity of the cérébral hémisphères. Towards the 
anterior extremity of the inner surface of thèse hémisphères, the arachnoid was 
raised on both sides by a purulent layer, which was displaced, but not removed, 
by passing the back of a scalpel over this membrane. The pia mater was infil- 
trated with pus through the entire extent of the fissure of Sylvius on the right side ; 
a layer pf this same liquid was found on the upper surface of the two lobes of the 
cerebellum. The upper wall of each of the latéral ventricles was very much 
raised, and presented an évident fluctuation. Each latéral ventricle contains, in 
fact, a greyish liquid, in the midst of which numerous flocculi float : thèse also 
accumulated in the lower part of the ventricles, form a thick layer which covers 
the cornu ammonis on each side. Some whitish laminœ were also found on the 
lower surface of the cérébral hémisphères. Thus surrounded on ail sides by a 
layer of pus, the cérébral substance underwent no appréciable altération, not being 
even injected. 

Thorax.— Anterior part of the two lungs empty of blood, whiist the posterior 
portion was gorged with it. The left cavities of the heart empty ; the right cavities 
contain a small quantity of liquid black blood. In the thoracic aorta is a fibrinous 
clot divested of colouring matter. The vena cava în the abdomen full of liquid 
black blood. 

Abdomen. — The convolutions of the small intestine were distended with gases ; 
the transverse colon also contains a great quantity of them. The stomach, which 
was covered by the colon and the liver, was distended with a mixture of gas and 
liquid in its splenic portion, whiist it was contracted in its pyloric extremity ; the 
inner surface of the stomach of a brownish grey, through the whole extent of the 
great cul de sac ; the duodénum, and two upper thirds of the small intestine, con- 
tained a great quantity of a yellow, viscid liquid, which colours very deeply the 
internai surface, and particularly the valvulœ. This portion of intestine, when 
washed, présents no appearance of injection. The lower third of the small intes- 
tine contains a greenish matter more liquid, but not viscid ; its inner surface is 
pale, except in three places, where there is observed a deep red colour, the seat 
of whïch is in the mucous membrane. Here we found three patches forming 
a slight projection above the level of the rest of the mucous membrane, each of 
them being about the size of a flve-franc pièce. For the extent of four fingers 



DISEASES OF THE EXCEPHALON. 



27 



above the ileo-cœcal valve, the inucous merabrane was uniformly injected. The 
large intestine contains a greenish liquid ; its inner surface présents through its 
entire extent a slight injection of the mucous membrane. The liver is remarkably 
large ; it extends into the left hypochondrium, and is interposed between the ab- 
dominal parietes and the spleen, to which it is united by cellular adhésions ; its 
tissue is, in some degree, gorged with blood ; it présents a red ground, traversed 
by numerous white lines. Spleen large and very soft. The bladder, which is 
contracted, contains not a drop of urine, and its mucous membrane is injected, and 
on one part of it there is a small eschar. 

Remarks. — The group of symptoms presented by this individual bear much 
closer resemblance to those appertaining to a severe dothinenterite, than to those 
connected with acute meningitis. On the dead body we found the latter very 
much developed ; but there were also indisputable, though very slight traces of a 
morbid state of the intestinal follicles. It was certainly on their inflammatory en- 
gorgement that those three red marks depended, which projected above the level 
of the intestinal surface, the existence of which we found not far from the cœcum. 
We may further observe, that this person had but recently arrived in Paris ; or 
the other hand, he had passed the âge at which persons are usually attacked with 
dothinenterite. The moral causes which had been operating on him, seemed 
more particularly to have disposed him to a cérébral affection. In subséquent 
parts of this work, we shall meet more than one case in every respect analogous to 
this with respect to the symptoms, in wilich, however, the nervous centres pre- 
sented no appréciable lésion after death. A question may be raised, whether this 
meningitis, so remarkable for its extent and for the quantity of pus effused into the 
pia mater and the ventricles, was not an additional phenomenon, or a complication, 
and whether it might not have been absent, and the disease still have retained the 
same form, observed the same progress, and been attended with the same severity ? 
Several facts, which shall be stated in another place, warrant us in thinking that 
the question may be answered in the affirmative. 

Case 24. — Thichening of the membranes on the convexïty of the hémisphères, and at 
their base — Tubercles in thèse membranes, and in the cérébral substance itself, 
which is red and softened around thon — Tubercidar diathesis — Symptoms of 
apoplexy at the commencement and termination of the disease. 
A man, thirty-three years old, had experienced, five days before entering the La 
Charité, ail the symptoms of an apoplectic attack ; the loss of consciousness con- 
tinued for twenty hours. On the following days he continued paralysed on the 
right side ; then delirium supervened, and the patient was admitted into the hos- 
pital after having been bled three times from the arm. He then presented the 
following state : — Face pale ; delirium ; equal facility in moving the extremities 
of the right and left side ; puise and tongue naturaL On the day after, Feb. 23, 
the eighth day of the disease, the delirium still continues ; air of restlessness 
sinking of the features ; puise hard, still not fréquent; tongue white and moist 
(sixteen leeches to neck). On the 26th, intelligence scarcely disturbed ; answers 
slow, but accurate (eight leeches to neck). 27th. Delirium returned ; puise now 
for the fîrst time has become fréquent. 28th. Eight leeches across each jugular 
vein. On the 2d and 3d of March, delirium complète, with fever (tweive 
leeches to the neck each day). This state continued with very little change for 
the twelve days following, during which leeches were frequently applied to the 
neck, when, on the 16th, the patient suddenly fell into a state of the most profound 
coma ; at the time of the visit he seemed like a man who has just had a violent 
attack of apoplexy. He expired some hours after. 

Post mortem — Cranium. — The arachnoid lining the inner surface of the dura 
mater readily séparâtes from it ; the membrane covering the entire convexity of 
the cérébral hémisphères is opaque, very white, and several lines thick \ the pia 



28 



CLINIQUE MÉDICALE. 



mater is the principal &eat of this thickemng. On the lower surface of the left 
hémisphère, towards its middle part, we observe in the méninges opaque portions 
similar in appearance to the méninges of the convexity ; but here other peculiari- 
ties are also observed : thèse opaque portions principally exist in the intervais 
between three or four circumvolutions ; the anfractuosity, which should sepa- 
rate them had disappeared, and thèse circumvolutions closely adhère to one 
another. On the infiltrated and thickened pia mater which unités them, there are 
observed small whitish miliary granulations, of a tubercular appearance, set in 
order like so many beads. In the grey substance of the adhering convolutions, 
there appear several of thèse granulations ; around each of them the cérébral sub- 
stance is very much inje-cted and softened for the extent of some lines. 

Thorax. — Similar granulations are also found in great quantityin the substance 
of the two lungs, and some also in the pleurœ. 

Abdomen. — The inner surface of the stomach white, and slightly injected 
towards the great cul de sac ; a tumour, the size of a nut, projects on the inte- 
rior of the stomach towards its great curvature ; when eut into it was found to 
consist of a sac, the raised mucous membrane forming its parietes, and the cavity 
being filled with softened tubercular matter ; this sac communicated with a large 
tubercular lymphatic ganglion attached to the great curvature of the stomach. 
The upper portion of the small intestine a little injected ; some tubercles were 
found between the peritoneum and muscular coat of the intestine ; the mesenteric 
ganglia very large. In front of the vertébral column there was found an enormous 
tubercular mass, consisting of the ganglia which exist ordinarily around the réser- 
voir de Pecquet ; the same tubercular ganglia are found in the thorax ail along the 
thoracic duct ; a large tubercular mass exists also in the fissure of the spleen ; 
other tubercular masses fill up the différent furrows of the liver ; in the interior of 
the liver w r e observed several small round bodies, white, and of considérable hard- 
ness, presenting at their centre a yellow point ; similar bodies are found in the 
central part of the kidneys, but without the yellow point in their centre ; three or 
four of thèse bodies were also found in the pancréas. 

Remaries. — This disease, after commencing with ail the symptoms of an apo- 
plectic attack, entirely changed its form. The apoplectic phenomena disappeared 
altogether ; not a trace even of the paralysis which followed the loss of con- 
sciousness remained. But another scène commenced ; and we behold most of 
those symptoms develope themselves belonging to the disease designated by 
Huxham under the name of slow nervous fever. On the part of the nervous cen- 
tres, we detect no other functional disturbance, except that of the intelligence, and 
even that is not permanent. The disease, after lasting twenty-nine days, returned 
to its original form, and the patient was carried off in a few hours with the 
symptoms of apoplexy. The post mortem examination presented very remark - 
able lésions. The state of the méninges of the convexity of the cérébral hémi- 
sphères, accounts for the disturbance of the intelligence, but it does not explain the 
alteraate increase and decrease of the delirium. The lésions at the base were of 
the same nature as those on the convexity of the brain. We must not lose sight 
of those red softenings scattered through the grey substance of some of the cir- 
cumvolutions, and of those precisely whose investing membranes were also 
diseased. Was this part of the brain the seat of the apoplexy, in which the disease 
terminated ? This appears so much the more probable, as the paralysis was on 
the right side, and itwas at the base of the middle part of the left hémisphère 
that thèse softened points existed. But why did the symptoms of apoplexy disap- 
pear ? Why did the paralysis cease ? No doubt, because the cérébral lésion, being 
at first but slight, disappeared of itself. But by reasan of the disposition to 
tubercular sécrétion existing in this individual, tubercles took the place of the 
blood that had been effused into the cérébral substance, whilst they were also de- 
posited in the cérébral membranes. At a later period, no doubt a new infiam- 



DISEASES OF THE ENCEPHALOX. 



29 



matory process took place around each cérébral tuberele. and thence perhaps y*?.Q 
aew attack of apoplexy which carried ofF the patient. 

Case 25. — Pain of head of very long standing — Suddenly deUrium; then coma — 
Symptoms of apoplexy and death — Purulent effusion on the convexity of the 
cérébral hémisphères, al the base of the brain and into the ventricles — Old cellular 
adhésions of the two folds of the arachyxoid — ossification of the retina. 
A shoe-maker, thirty-eight years of âge, of strong constitution, deprived of the 
left eye from his infancy, was troubled ail his life with pains of the head, the seat 
of which he usually referred to the left side of the cranium ; fourteen months 
previous he received some violent blows on the head in a fîght, since which 
occurrence his headachs became more fréquent and more severe ; he often feels 
a dizziness. On the 13th June, after his work, he complained of gênerai iliness, 
and of a more violent headache than ever over the left side of the cranium : 
during the night he became very feverish. On the 15th he was bled. On the 16th, 
some delirium at intervais. On the 17th, constant stupor (a blister was applied 
to nape of neck). On the 18th he entered the La Charité, and on the I9th (the 
seventh day of his iliness) he presented the following state : face pale ; eyes shut ; 
appearance of tranquil sleep, from which it is almost impossible to arouse him ; 
when he does open his eyes he looks around him with a stupid air, utters not a 
word ; power of motion perfect, but'seusibility diminished ; passes his fasces under 
him. — (one ounce of sulphate of soda, sinapisms). On the 20th, No change. 21st. 
Puise accelerated ; beat of skin very much raised ; still comatose ; subsultus in 
both arms ; bled from the arm ; blood covered with a thick coat. On the 22nd 
new symptoms were observed ; left eye-lid remained depressed over the eye ; 
the right eye, on the contrary, wide open, fixed and dull ; pupil of this side 
dilated aud immoveable ; at each expiratory movement the left cheek was 
pushed out, announcing commencing paralysis of the muscles of this side of the 
face. The right arm, when raised, fell again as an inert mass ; subsultus in the 
two fore-arms. Pinching the skin gives not the least pain ; respiration stertorous ; 
puise fréquent and strong ; skin covered with sweat. In the course of the day 
the coma became more and more profound, and the respiration more difficult, and 
at five in the evening he died. 

Post mortem — Cranium, — Cellular adhésions, similar to those often uniting the 
pleura, extended from the arachnoid covering the hémisphères, to that lining the 
dura mater. The pia mater, in the upper surface, very much injected. The 
latéral ventricles were distended by a great quantity of a whey-like liquid. The 
méninges of the brain were generally injected. A thick purulent layer, which was 
seated in the pia mater covered the left cérébral peduncle, the left portion of the 
medulla oblongata, and extended, like a sheath, over the nerves arising from this 
part. Nothing remarkable in the thorax or abdomen. 

Examination of the left eye. — The transparent cornea was thick and opaque ; the 
opening of the iris was completely obliterated by a white membrane several lines 
thick, the edge of which adhered to the circumference of the iris ; no longer 
any trace of the crystalline lens. The vitreous humour had a milky appear- 
ance. Not a trace of retina, but in its place we found a small bony shelL 
having a small hole in the centre ; its concave surface was applied to the corpus 
vitreum ; no vestige of the ramifications of the optic nerve was discovered on it. 
The left optic nerve was smaller than the other, and of a grey colour, from the 
sella turcica to its entrance into the eye ; it terminated at the central hole in the 
bony shell above described, by a but {bouton) apparently fibrous, and similar to 
the swelling found in the extremities of nerves in amputated limbs. From their 
origin to their crossing the two optic nerves were perfectly similar. 

Remaries. — In this individual two species of altération were found within the 
cranium, and ail two had their share in the production of the symptoms. The one 



30 



CLÏNIQUE MÉDICALE. 



ûf thèse altérations was of a long standing 1 , namely, the cellular adhésions uniting 
the two layers of the arachnoid. It is very probable, that on thèse depended the 
headachs which so long annoyed the patient. Anatomy, however, does not 
inform us why the pain of the head was more severe on the left than on the right. 
The exaspération of this pain of head, raarked the commencement of the acute 
disease, for which he entered the hospital, and which was sufficiently accounted 
for by the purulent effusions found on the upper surface of the brain, its base, and 
in the ventricles. We may observe, that the purulent layer of the base was con- 
fîned to one of the cérébral peduncles, the left, and also to the left pons varolii and 
medullaoblongata. Wemay also observe the purulent sheath,surroundingthenerves, 
arising from the left side of this part of the brain. Is it in conséquence of thèse 
anatomical circumstances that, towards the termination of the disease, the left eye- 
lid, and cheek of the same side, became paralysed, at the same time that ail motion 
seemed extinct in the right arm? Violent pain of head, fever, gênerai illness, 
were ail that we observed during the first days of the disease. Some delirium set 
in on the 4th, which, on the 5th, was succeeded by a state of coma, which went on 
increasing to the lOth day, when he died, a little after symptoms of paralysis 
appeared. To explain this succession of phenomena, shall we say that the méninges 
of the convexity of the hémisphères were, at first, irritated, and that it was then the 
delirium appeared, and that the coma which succeeded this delirium, announced 
the extension of the meningitis towards the base of the brain and into the ventricles? 
We have already seen, however, that it is not always possible to détermine, from 
the prevailing symptoms, what portion of the méninges is especially affected. The 
circulation did not présent that slowness here which it did in other cases. The 
puise, which was natural on coming to the hospital, became fréquent and fébrile, 
in proportion as the state of coma became more and more developed. We have 
observed the contrary in other cases. 



CHAPTER V. 

DISEASES OF THE MEMBRANES OF THE SPINAL CORD. 

Case 26. — Spinal arachnitis — Arachnitis of the base and convexity of the brain — 
Milky sérum in the ventricles.* 
A woman, twenty-eight years of âge, the mother of four children, had been very 
much distressed by certain insulting proposais made to her ; her menses were 
suddenly suppressed in the midst of their course, and she was instantly seized with 
violent shivering, which lasted twenty-four hours. The next day, great heat of 

* The following very interesting cases, which serve to illustrate the principal circumstances 
connectée! with disease of the upper cervical vertébrée, are condensed from Dr. Bright's Médical 
Reports, vol. ii. part 1, page 415. They were communicated to him by Mr. Key : — 
Case 1. — Slight Paralysis from disease of the Cervical Vertebrœ. 

A young lady, aged thirteen, had been for about twelve months troubled with pain in the 
neele, which at first was considered as the effect of a cold. This not going off, was treated by 
her médical attendant as a glandular affection. This pain continued to increase, until at last 
she could not rise from the horizontal position without great pain, being also obliged to support 
lier head by placing her hands on each side. When Mr. Key first saw her, she was emaciated, 
and her countenance betrayed great suffering. On examining her neck there appeared a 
gênerai fulness, which gave her pain on pressure ; she had the power of slightly moving the 
head backwcuds and forwards, but the latéral movement was accompanied with so much pain 
that she could not be prevailed on to attempt it. The case seemed evidently an affection of 
the two upper cervical vertebrae. After some time a tumour was perceived at the back of the 
pharynx, which, on punctuxe, yielded about three ounces of pus, and which Mr. E. concluded 



DISEASES OF THE ENCEPHALON. 



31 



skin ; burning thirst ; a sensé of squeezing at the throat ; bolus hystericus very 
marked. On the third day, bilious vomîting ; she vomited also whatever drink 
she took. On the fourth day, still vomits ; hysterical symptoms gone ; she entered 
the hospital in the evening, and on the following morning presented the following 
state :~fifth day, countenance very much flushed ; eyes very bright ; neck swollen ; 
head turned back and flexed laterally, could not be inclined forward without 
causing great pain ; constant pain extending along the vertébral column, from the 
great occipital foramen to the sacrum ; the least movement causes the patient to 
scream from pain ; pain not increased by pressure ; respiration embarrassed, and 
panting; puise fréquent; skin hot and dry; tongue natural ; had no stool for the 
last forty hours (flfteen leeches to the anus; purgative lavement; mustard 
pediluvia ; demulcent drinks ; soothing frictions over the spine). Sixth day, pain 
less (blister to the nape of the neck; twenty-four leeches behind each car). 
Seventh day, sleep disturbed ; increased sensibility of the head and back ; tétanie 
rigidity of the back of the neck and trunk ; countenance pale and expressive of 
pain ; respiration more painful than before ; puise the same (bleeding from the 
arm ; blister to the sacrum ; sinapisms to the legs ; assafœtida lavement). Three 
minutes after the bleeding, the blood was buffed and cupped ; at the end of an 
hour, the patient very much relieved in every respect, and the bleeding was 
repeated. Some delirium on the eighth day, when she was bled again. On the 
ninth, the blood drawn exhibited the same infiammatory appearance as that of the 
two first days ; pain of head and back more intense ; features sharpened and very 
much changed ; answers to questions slow and painful. — (twenty-four leeches along 
the vertébral column ; laxative lavement). At four o'clock in the evening, she no 
longer answers questions ; constant moaning ; subsultus tendinum ; puise small 
and fréquent ; respiration short. On the tenth day, cold and clammy sweat over 
the face ; ail the other symptoms were aggravated, and she died at noon. 

Post mortem. — The spinal canal was opened for its entire extent, and on cutting 
into the dura mater we found a layer of whitish, opaque, membranous matter 
extended over the spine, from the great occipital foramen to the sacrum ; on 
pressing it with the finger, a turbid liquid, mixed with albuminous clots, are made 
to flow into the cranium ; on drawing the scalpel over this membranous layer, the 
instrument slides on and takes up nothing, which seems to indicate that there is a 
membrane above this layer; dissection soon proves it. On detaching the arachnoid 
from the inner surface of the dura mater, we discover that the diaphanous mem- 
brane, covering the purulent layer, is but a continuation of it ; it is evidently the 
portion of the arachnoid which, under ordinary circumstances, covers the pia 

had communication with the diseased spine. This gave some relief ; hut her emaciation and 
suffering increased. Ahout a fortnight hefore her death, vomiting came on whenever she took 
food, which was allayed by a blister applied in the course of the par vagum in the neck ; she 
had convulsive twitchings of the upper extremities, and a slight paralytic affection of one arm. 
She sunk graduai ly. 

The second case was that of a young man, aged t wenty-three years, who seemed to labour 
under an affection similar to the last, with a strong tendency to phthisis. Connected with the 
disease there appeared a tumour in the neck on the right side, just behind the angle of the jaw, 
which projected into the pharynx ; on puncturing this, a quantity of pus escaped, which gave 
great relief to his breathing and to his pain. The tumour formed again in four days after, and 
buist, and it does not appear that it gathered afterwards ; the external tumour disappeared. 
He complained of some soreness low down m the œsophagus in swallowing ; there was a slight 
latéral protrusion of the second vertebra. 

The third case was that of a young man, eighteen years old, who complained of great stiff- 
ness with swelling at the back of the neck, which he had been complaining of for six months, 
and which was considered rheumatic. He could not rise from the recumbent position, nor 
move his head, without much pain ; he gradually wasted away. He expired suddenly, in the act 
of being raised from his pillow ; probably from the anterior ligament of the processus denta- 
tus at that moment giving way. A slight tendency to parai ysis of the upper extremities was 
observed on the morning of the day lie died. 



32 



CLINIQUE MEDICALE. 



mater, and which is here separated from it by a layer of pus. Hère then the pus is 
found exhaled, not into the cavity of the serous membrane, but on the external 
surface of this membrane, in the cellular tissue uniting it to the pia mater. On the 
brain, the arachnoid and pia mater are very much injected towards the fissure of 
Sylvius. On the right side we find an albuminous concrétion, similar to that w hich 
fîlls the vertébral canal ; we also find another, still thicker, on the external surface 
of the right hémisphère, near tbe great interlobular fissure. Concrétions similar 
to the preceding are found beneath the tentorium cerebelli, and a still greater 
quantity than elsewhere between the low r er surface of the cerebellum and the base 
of the cranium. The latéral and third ventricles were very much distended by a 
great quantity of milky sérum, Thoracic and abdominal viscera sound. 

Remarks. — This case présents a combination of the différent symptoms which 
characterise, in the most striking manner, acute inflammation of the membranes of 
the spine. Yet, at first, it did not commence by thèse symptoms : it might have 
even been taken for a simple neurosis, and probably it was then nothing more ; we 
think that there are many cases of this kind, and that some inflammations are 
preceded by mere nervous disturbance, in which the disease then entirely consists ; 
at which moment, narcotics have a marvellous power of dissipating the symptoms, 
but if it be allovved to proceed, it will soon change its nature; and those functional 
disturbances which, a while ago, were the expression of an affection merely of 
innervation, will afterwards be produced and kept up by an inflammatory process, 
where narcotics would be mischievous, and other means must be resorted to. 

During this first period, which appears altogether nervous, those vomitings also 
appeared, which are so often connected with cérébral affections, mark their onset, 
and précède their characteristic symptoms. It is only from the fourth to the fifth 
day, after the appearance of thèse différent symptoms, that the first phenomena, 
indicative of the nature and seat of the disease, disclosed themselves. The intelli- 
gence remained for a long time unaffected ; whilst, on the contrary, sensation and 
motion became seriously altered. In none of the preceding cases have we seen 
anything similar to the acute pains felt ail along the vertébral column, accompanied 
by some tétanie symptoms. Cérébral meningitis also existed ; and it is not impro- 
bable that the inflammation ascended from the spinal canal into the cranium only 
towards the termination of the case. We are disposed to consider that the 
difficulty of respiration arose from the circumstance of the spinal cord, in which 
we include the medulla oblongata, being the spécial seat of the disease. The 
moral cause which brought on the suppression of the catamenia is an additional 
reason for our considering that the affection, in the first instance, was merely 
nervous. 

Case 27. — Spontaneous luxation of the first two cervical vertebrœ — Hemiplegia. 

A man, thirty-five years of âge, of a strong constitution, had always enjoyed 
good heaîth, except that he twice had syphilis, for which he says he was properly 
treated. After having suffered considerably from pains in différent parts of the 
body, in the left knee, in the région of the kidnej'-s, and the left thigh, he was then 
attacked with pain in the left side of the head, which soon spread to the same side 
of the face ; some time after he began to complain of his neck, the motions of which 
became very much constrained ; about a month after this the patient discharged 
by the mouth a great quantity of pus. The médical man who saw him at this 
time thought that the purulent discharge came from an abscess which formed 
betw r een the pharynx and vertébral column, and which opened into the pharynx. 
However, it ceased at the end of seven days ; but from this period the patient's 
countenance changed rapidly ; he w'asted aw r ay ; continued to feel pain in the left 
side of the neck, his head inclined over the right shoulder, and his face was directed 
towards the same side. Some weeks after, the fingers of the left hand bécarre the 
seat of a pricking sensation ; the day after they w T ere, as it were, benumbed, and 



DISEASES OP THE ENCEPHALON. 



33 



couîd not be moved without difficulty ; the day following, the entire upper extre» 
mity of the left side was deprived <)f motion; next day he felt the lower extremity 
of the left side a little weaker than the right. He entered the hospital on the 
lOth of June, and presented the following state : lies on his back, head and face 
inclined to the right, without any sensible contraction of the sterno-mastoid 
muscles ; lancinating pain throughout the left side of the head ; left pupil not so 
much dilated as the right ; conjunctiva of this side considerably injected ; left 
eyelid hangs a little over the eye ; vision equal on both sides ; intellect sound ; 
total loss of the contractile power of ihe left arm ; its sensibility entire ; percep- 
tible diminution in the motions of the left lower extremity ; tongue a little red, 
There was an issue in the nape of the neck, which was still retained. On the day 
after, the head having been a little deranged from its position during the dressing, 
and inclined somewhat to the left, as also the face, the two extremities of the right 
side instantly lost the power of moving ; they recovered it the moment the head 
resumed its usual position. On the nights of the three following days, delirium 
set in, puise fréquent. Sinapisms were ordered. Two days after, at six o'clock in 
the morning, the patient was in the same state as on the preceding days ; he con- 
versed quietly with the other patients who were near him, and there was no sign 
as yet of his dissolution being at hand. At seven o'clock he suddenly lost the 
faculty of speech ; his body was covered with a cold sweat, his respiration became 
remarkably slow, then stopped altogether, and he died at half-past seven. 

Post mortem 25 hours after death. The brain being examined with the greatest 
care, presented no appréciable lésion in its substance ; its ventricles were nearly 
empty ; the external arachnoid was considerably injected. Immediately on sepa- 
rating the pons Varolii from the medulla oblongata, we perceived sanious pus of a 
reddish grey colour flow in great abundance from the great occipital foramen. 
The transverse ligament of the atlas which séparâtes the spinal cord from the 
odontoid process, was entirely destroyed, and this process was in immédiate con- 
tact with the cord, which being pressed by it, was transformed on that part into a 
soft pap. The entire process was rough and uneven. The superior articulating 
cavity of the atlas on the left side did not hold by any ligamentous connection or 
any capsule to the condyle of the occipital bone ; both presented a dark rough 
appearance, and were bathed in an immense quantity of pus. The left portion of 
the posterior arch of the atlas was also carious. The inferior articulating process 
of the atlas, and the superior process of the dentata of the right side, were also 
separated from one another, and their surface were black and rough. Finally, the 
left portion of the anterior surface of the body of the dentata was equally deprived 
of periosteum, and presented numerous asperities ; it was separated from the 
pharynx by a purulent collection of a dirty grey colour, which communicated with 
this passage by afistulous opening, the orifice of which corresponded to the fourth 
cervical vertebra. 

Remarks. — Let us now endeavour to connect the lésions found after death with 
the symptoms during life, and let us see how far the one may clearly explain the 
other. In the first place, it is évident that the purulent discharge which took place 
by the mouth, about two months before death, had the origin ascribed to it by the 
médical man who saw him at the time ; it is probable that some pus flowed every day 
through the fistulous opening in the posterior wall of the pharnyx ; but coming 
only in small quantities at each time, it passed probably into the stomach. It is 
again probable that the disease of the first two cervical vertébrée commenced long 
before it manifested itself by any well-marked symptom ; but in proportion as this 
disease advanced, the différent ligaments securing the connections of the occipital 
bone and the first two vertébrée, were destroyed gradually, and at last became 
totally disorganised. As soon as this destruction was carried to a certain degree, 
the displacement of the articulating surfaces was the inévitable conséquence ; 
thence compression of the cord by the luxated vertébrée. There was a luxation 



34 



CLINIQUE MEDICALE. 



on the right as well as on the left. The inclination of the head and face to the 
right shows that the displacement took place principally on the left, at the atloido- 
occipital articulation ; the paralysis also existed on this side. One day a momen- 
tary paralysis was noticed on the right side, in conséquence of a slight change in the 
position of the head. This circumstance is easily accounted for, by supposing that 
in this change of position the diseased articulating surfaces of the right side came 
to ride one over the other. The permanent inclination of the head without con- 
traction of the sterno-mastoid muscles, might have inclined one to suspect luxa- 
tion of the vertébrée. The manner in which the head inclined over the shoulder, 
without the neck seeming to participate in this flexion, as happens in the natural 
movements, indicated that the luxation took place very high up. It must be 
admitted that at first the odontoid process underwent but very slight displacement. 
But a period arrived when, whether after some sudden movement, or in con- 
séquence of the destruction of the transverse ligament, the spinal marrow came 
to be compressed and disorganised by this process. This phenomenon may be 
referred to the time when the patient suddenly lost the faculty of speaking, and 
when his respiration became embarrassed : death supervened as soon as the dis- 
organisation of the cord was such as to incapacitate it for the discharge of ils 
functions. Some would connect the caries of the vertebrœ in this case with the 
syphilitic attack under which the patient had previously laboured. 

Case 68*. — Phenomena obscure at the commencement of the disease — Constipation — 
Rétention of mine — The fifth day, paralysis affecting the motion of the hiver 
limbs, with morbid exaltation of the sensibUity — Rigidity of the neclc and trunh, 
accompanied with pains along the spine on raising the patient — The seventh dau, 
the saine phenomena in the upper extremities, bid in a less degree — They became a 
little rigid — Symptoms gradually became more severe — Death at the commencement 
of the tenth day — Pnriform exudation between the arachnoid and pia mater of the 
cord — Injection of the cérébral vessels — Turbid sérum in the vent rides. 
A man, twenty-four years of âge, of rather a strong constitution, entered the 
Hotcl Dieu, the 19th of October, 1828, stating that he had been ill for the last five 
or six days. He complained of no particular part as being the seat of acute pain ; 
his illness was gênerai, but slight ; still his countenance was expressive of suffer- 
ing ; his answers were slow ; lips seemed to tremble as when a person is going to 
cry ; no appréciable symptom of fever ; heat of skin nafural ; no symptoms of 
gastro-intestinal irritation. He remained for two days without undergoing any 
change. He arose out of bed and walked through the ward, but not haying 
passed any urine since entering the hospital (three days), the cathéter was intro- 
duced ; bladder very much distended. On the 24th Oct. (fifth day) M. Dance 
examined the patient more particularly ; his countenance still expressive of suf- 
fering ; seems always as if going to weep ; answers slow and vague, when ques- 
tioned regarding his state, about which he does not furnish any more information ; 
bladder still distended; on raising the lower extremities he screams with pain, 
particularly on moving the right lower extremity ; pinching felt equally in both 
limbs; sensation also perfect, but he cannot raise them ; he cannot even extend 
them after they have been flexed ; they fall back on the bed, as inert masses, if left 
to their own weight ; they are deprived of motion but not of sensation. The 
vertébral région was then examined, which presented nothing unnatural ; it was 
remarked that he could not replace himself on his seat ; that he suffered on the 
least flexion of the spine, and that the neck was slightly retroverted ; on attempting 
to incline it forward, it could be done only to a certain degree, and by causing the 
patient some pain ; he was now very irritable. In the upper extremities motion 

* A few Cases of Spinal Meningitis ave here added from Ollivier's Treatise on Diseases of 
the Spinal Cord. The nurnbers annexed: to the cases refer to Olliyier's work. 



DISEASES OF THE ENCEPHALON. 



35 



and sensation underwent no change ; puise has some frequency and a little hard- 
ness ; skin hot ; tongue natural ; no stool for the last five days ; no rigidity nor 
convulsions in the lower extremities (venesection, lavements). On the 25th, same 
state ; distension of the bladder ; puise fréquent ; skin hot ; limbs painful wnen 
moved, particularly that on the right side ; same state of countenance and slowness 
in the association of his ideas ; same pain on turning the patient (another bleeding). 
On the 26th the same appearance ; puise now very small and more fréquent ; 
bladder still distended ; urine fetid, turbid, and reddish, contains a gaseous fluid 
which is heard escaping by the cathéter, which is blackened by remaining even 
for a short time in the bladder ; blood last drawn buffed and cupped. In the 
evening state worse ; puise nearly extinct and very fréquent ; still the heart beats 
with considérable strength ; lower extremities sensible, but cannot move, and are 
very painful when any one attempts to move them. This paralysis and morbid 
sensibility begin to appear in the upper extremities, which présent a slight rigidity ; 
trunk and neck rigid ; countenance still expressive of sufrering ; answers slow but 
précise ; tongue moist ; évacuations from the bowels scanty. On the 27th same 
state ; parietes of the bladder have now lost ail contractility ; upper extremities 
weaker ; one stool (sinapisms to lower extremities). On the 28th, patient now 
much worse in every respect ; the contractile power of the upper extremities 
weakened ; they are half-flexed, and evidently rigid, as are the entire trunk and 
neck ; head somewhat inclined backwards and to the left ; right pupil more dilated 
than the left ; respiration slow ; motions of ribs incomplète ; bladder still distended ; 
escape of fetid gas with the urine through the sound ; no stool. Died on the 
29th, the tenth day of the disease. 
Post mortem thirty hours after death. 

Cerebro-spinal Cavity. — Marked injection and distension of the spinal vessels ; 
membranes healthy ; latéral ventricles very much distended, containing about three- 
fourths of a glass of sérum, somewhat opaque ; the other ventricles were also 
distended. The vertébral canal being opened through ail its extent, we observe, 
external to the dura mater, in the cellular tissue surrounding it, a net-work of 
vessels injected with blood. This membrane seemed very much distended and 
immediately applied to the cord, which already indicated a particular development 
of the parts contained in it. The dura mater having been eut into through its 
entire length, the cord appeared covered by a gelatinous layer, slightly yellowish, 
four or five Unes thick, which was applied immediately over the pia mater. This 
layer was very thick towards the lumbar enlargement of the cord, and there also 
the yellowish colour was deeper ; it gradually diminished in thickness in ascending 
as far as the third or fourth cervical vertebra, where it ceased altogether ; there 
was no trace of it on the cauda equina ; it was less thick and less perceptible on 
the anterior surface of the cord than on the posterior surface. This gelatinous 
layer was situate between the pia mater of the cord, and the corresponding 
arachnoid reflexion ; that which lined the dura mater was also covered with a very 
délicate false membrane granulated, and of little consistence. This puriform, 
concrète substance, subjacent to the arachnoid, was not liquid, whether by reason 
of its tenacity, or because it was contained in the meshes of the sub-arachnoid 
cellular tissue. The lower part of the spinal canal, beneath the arachnoid, con- 
tained four or five spoonfuls of opaque sérum. 

Thorax. — Lungs adhering at ail points of their surface, by organised cellular 
bands of long standing ; the right lung posteriorly, was evidently in the first degree 
of hepatisation ; its tissue friable and gorged with blood ; heart natural. 

Abdomen. — Mucous membrane of the stomach plaited, grey, slate-coloured, and 
even somewhat blackish, for a considérable portion of its extent ; in some parts it 
was studded with red dots, as if from ecchymosis ; that of the intestines was very 
much injected, reddish, and the intensity of this colour, which occupied the lower 
fourth of the intestine, went on increasing as far as the ileo-cœcal valve ; the 

d 2 



36 



CLINIQUE MÉDICALE. 



mucous membrane of tbe bladderwas tbickened, reddish, slate-coloured, evidentîy 
inflamed, and filled with thick, fetid urine. 

Remarhs. — This case présents, in a manner, the complète history of spinal 
meningitis, and the symptoms of this inflammation were, as we see, conformable 
to the lésions found on the dead body ; the invasion of the disease was obscure ; 
the patient remained four days in the hospital before we were able to détermine 
what his disease was. The first four days he arose ont of bed and walked about 
the ward ; so that it is évident the locomotive powers were not affected till the 
fifth day ; up to that period, paralysis of the bladder and rétention of urine were 
the only symptoms which could create any suspicion of lésion of the spinal cord or 
its membranes ; the functions of the intestines were at the same time destroyed, 
and constipation existed nearly from the commencement of the disease till death. 
Paralysis of the motive power of the lower extremities, with morbid exaltation of 
the sensibility, are the phenomena which then appeared, and to which were joined 
rigidity of the neck, inflexibility of the trunk, pains in the trunk and limbs on 
moving thèse parts. Such was the séries of the symptoms which manifested them- 
selves successively in the course of the spinal meningitis. Again, if we consider 
the peculiar appearance of the countenance, the difficult association of ideas, the 
slowness of his answers, which were noticed from the commencement, it may 
probably be supposed that the cérébral lésion preceded that of the membranes of 
the cord : so, in fact, it appears to me ; but the changes found in the encephalon, 
and which are also entirely conformable to the state of the cérébral functions during 
the disease, were not of a nature to have influenced the progress of the spinal 
meningitis ; they probably contributed to throw obscurity over its first pro- 
gress. What makes it probable that they could not exercise any influence on 
the progress of the spinal meningitis, is, that the latter manifested itself by symptoms 
which proved its ascending progression, and its commencement in the lower 
portion of the cord. It may be remarked, that the neck becoming rigid, and the 
upper extremities losing their strength, were subséquent to the paralysis in the 
motion of the lower extremities. The muscular movements were abolished in the 
bladder, the intestine, and the lower extremities, whilst the upper extremities had 
lost but a portion of their motive power ; and the pseudo-membranous layer was 
found, in the dead body, much thicker inferiorly than superiorly, which seemed to 
indicate that the inflammation had been of longer duration, and of a less récent 
date in the former région. The pain felt by the patient on moving the limbs or 
trunk, may, perhaps, be explained by the slight dragging, or shaking, which the 
inflamed membranes of the cord then suffered ; the same phenomenon being also 
observed in pleuritis, where the slightest pressure increases the sufferings of the 
patient. The involuntary contractions of the vertébral muscles, which rendered 
the spine like an inflexible stock, seem also the resuit of those instinctive motions 
which we so often exécute for the purpose of avoiding or preventing pain. The 
vertébrée, by becoming fixed one upon the other, prevented the spinal membranes 
from experiencing so much dragging. The morbid exaltation of the sensibility 
seems to be one of the characters of spinal meningitis. 

According to Lallemand,the sensibility is not as often abolished as the power of 
motion, because the nervous centres are in two very différent physiological con- 
ditions in the production of motion and of sensation ; they are active in the per- 
formance of the former, whilst for sensation they are merely passive ; they only 
receive the impression. The rigidity and semi-flexed state of the upper members 
observed in this case, support M. Lallemand's opinion, who considers convulsion 
and rigidity of the limbs as a symptom of inflammation of the coverings of the 
nervous centre. In this case, traces of inflammation were found in the îungs, 
stomach, and bladder. The state of the lungs may be easily accounted for by the 
difiiculty of the respiration during the last period, The state of the stomach and 
intestines gave rise to no symptom, except we rcfer to it the burning heat of skin, 



DISEASES OF THE ENCEPHALON. 



37 



and the great thirst. We are inclined to think that those inflammations so often 
met in thèse cases are the effect of sympathie re-action, and of the numerous con- 
nexions uniting the spinal cord to the respiratory and digestive organs. With 
respect to the cystitis, it was attributable no doubt to the décomposition of the 
urine, and to the irritation caused by the sound in the bladder. What was remark- 
able in this case, is, that the symptoms were continued, those painful tétanie 
contractions so characteristic in such affections, which corne on at irregular periods, 
and are fol'lowed by more or less remission, not having- been here at ail observed. 

Case 72*.— Permanent tétanie contractions, accompanied with symptoms of cérébral 
meningitis — Deatk on the ninth day — Puriform exudation at the base of the left 
hémisphère, and in the middle of the dorsal région, under the arachnoid — Gelatinous 
infiltration ofthe cellular tissue, external to the spinal dura mater. 

A maie child, between three and four years of âge, was brought to the Hôpital 
des Enfans- Trouvés. The first symptoms were very great difficulty of déglutition ; 
remarkable fixedness of the eyes, to which were soon joined tétanie symptoms : 
trismus, opisthotonos.— (repeated application of blisters behind each ear, sinapisms 
to the lower extremities, frictions, tepid baths produced no amélioration). The child 
was continually comatose. Died on the ninth day. 

Post mortem. Cranium. — Cérébral substance very much injected and firm ; the 
grey substance of a very deep colour ; white substance of a pearly aspect, contain- 
ing some injected vessels, particularly around the ventricles, which contained a 
considérable quantity of sérum. Their lining membrane thickened and injected. 
That of the lower part of the left hémisphère was covered by a thin albuminous 
concrétion, and the same membrane presented a very bright red injection on the 
convexity of the two hémisphères, and in some parts of the cerebellum. 

Spine. — In the middle of the dorsal région, there was a reddish infiltration of 
considérable consistence, in the cellular tissue between the dura mater and the 
bony canal of the spine. On making an incision into the membranes, their cavity 
was found filled with sérum : the vessels on the surface of the pia mater were 
very much injected, in the middle of the dorsal région only, where the arachnoid 
covered an albuminous concrétion of about four inches in length. The substance 
of the cord a little more injected than natural. 

Thorax. — The pleura pulmonalis of the right side adhered to the pleura costalis 
and to the diaphragm by a false membrane of some thickness, and not organised. 

Abdomen. — The stomach, which was contracted on itself, contained some frothy 
mucus. The mucous membrane of the small intestines also was covered with a 
grumous whitish mucus. That of the large intestines was of an intense red colour, 
through ail its extent. The mesenteric ganglia were very large, soft, and white. 
Liver pale. 

Remaries. — The spinal meningitis, though circumscribed, contributed no doubt to 
cause the tétanie contraction of the trunk in this case ; yet we must also take into 
account that the cérébral meningitis must also have exercised some influence in 
producing this phenomenon, it alone being in some cases sufficient to produce the 
rétroversion of the neck. It is évident from this case that inflammation of the 
membranes of the cord may be confined to a portion of their extent more or less 
circumscribed ; we shall presently see another case fully demonstrating this patho- 
logical fact. There was also found a gelatinous and red'dish infiltration in the 
cellular tissue, external to the dura mater ; and I shall here remark, that this 
change appears to be sometimes the sole product of spinal inflammations. The 
existence of thoracic and abdominal inflammation, which is so fréquent a coïnci- 
dence with affections of the spine, is to be set down as a conséquence of the physio- 
logical and pathological relations Connecting this nervous centre with the différent 
apparatuses of organic life. 

* OUivier, vol. ii. p. 585. 



38 



CLINIQUE MEDICALE. 



Case 73*. — JDeep-seated pain m the lumbar région, after a violent effort ; cérébral 
symptoms followed by debility, and partial paralysis of the limbs ; urine and fœccs 
discharged involuntarily — Death twelve days after the appearance of the latter 
symptoms — Effusion into the right ventricle; meningitis of the convexity of the left 
hémisphère ; capillary injection, ofabout an inch in extent, beneath the arachnoid 
oftke meningeal sheath of the cord in the lumbar région. 
A man, twenty-eight years of âge, entered the hospital La Charité, April 4, 1823. 
He had been treated at the Saint Louis for a deep-seated pain which he felt in 
the lumbar région, after a violent effort to raise a load in September, 1822. A 
blister was applied over the. seat of pain, which was very long in healing. On 
entering the La Charité, he complained of gênerai debility ; he was very much 
dejected, and considerably emaciated. On the 7th of the month, he presented 
the following symptoms : — extrême difficulty in answering questions, inability to 
articulate certain words ; mouth slightly inclined to the right ; face a little red ; 
left arm weaker than the right ; sensation and motion of the lower extremities 
natural ; urine and fseces passed involuntarily.— (arnica, blisters to legs, purgative 
lavement). On the 8th, several stools, puise slow ; mouth straight, countenance 
pale ; unable to articulate one word ; motion of the left arm more difficult than 
that of the right. — (volât, linim. with tinct. cantharid. to be rubbed on the limbs). 
On the 9th, both arms move equably ; loss of consciousness. On the lOth, 
déglutition impossible ; he manifests some pain when his legs are taken hold of 
to dress the blisters ; respiration fréquent, not stertorous. Died at ten o'clock in 
the morning. 

Post mortem (twenty-two hours after death). Extemal appearance. — General 
emaciation ; great rigidity of the limbs ; chest flattened and narrowed. 

Head.— Vessels of the brain gorged with blood, patches of a yellowish grey 
colour on the surface of the left hémisphère, formed by a concrète substance 
effused under the arachnoid ; considérable serous effusion into the right ventricle. 

Spine. — Whitish turbid sérum (about an ounce and half) in the lumbar portion. 
On the right side a sort of ecchymosis, an inch broad, formed by a number of small 
capillary vessels injected, subjacent to the arachnoid lining the dura mater ; the 
injection deeper in the centre ; the arachnoid was neither thicker nor more opaque 
on tins part, which corresponded to about the third vertebra. Its inner reflexion 
was separated from the pia mater of the cord, posteriorly only, by a frothy sérum 
which diminished towards the upper part. 

Thorax. — Some adhésions of the left lung to the pleura. Its inferior lobe pre- 
senting pneumonia in the third stage ; pus escaped frora it on making an incision ; 
upper lobe filled with miliary tubercles in différent degrees of softening. It crepi- 
tated however. Entire of the right lung adhèrent, crepitating, filled with grey 
granulations. 

Abdomen. — Liver occupies the two hypochondria, concealing the stomach ; it 
was gorged with blood. Veins of the stomach dilated. Small intestines presented 
some partial redness in their interior. Bladder dilated, urine deep-coîoured, fetid, 
not ammoniacal ; its mucous membrane pale. 

Remarks. — The continuance of the pain in this case, and the relation existing 
between its seat and that of this isolated inflammation, incline us to think that the 
effort made to raise the heavy load had been the cause of it. The patient was in 
some respect cured of this when he entered the hospital, and died of cérébral 
meningitis. The turbid liquid found in the spinal membranes came probably from 
the cavity of the cranium, being a portion of that which distended the ventricles. 
The cases now given belong to acute spinal meningitis ; and the symptoms, as 
well as the changes found after death, show what great influence the spinal cord 



* Ollivier, vol. ii., p. 589. 



DISEASES OF THE ENCEPHALON. 



39 



possesses over the organs of nutritive life, in which we very frequently find évident 
traces of an inflammation, which was developed during the course of the spinal 
affection. But when the meningitis is chronic, its symptoms are less obvious, 
consisting merely in obscure pains of the back, with a feeling of restraint and 
fatigue in the limbs, and the attention is in gênerai exclusively directed to the 
morbid phenomena which arise from the viscera secondarily affected, the true causes 
of which are too often misunderstood. Colouring more or less deep of the mem- 
branes, and a thickening of them are the ordinary anatomical characters of this 
chronic inflammation, which also usually leaves after it cellular adhésions between 
the arachnoid and pia mater, and between the two arachnoid reflexions. 



RECAPITULATION. 
CHAPTER I. 

LESIONS DETECTED IN THE MENINGES BY POST MORTEM EXAM1 NATIONS. 

ARTICLE I. 
Lésions of the Dura Mater. 
Lésions in the dura mater are much more rarely met with than in the two other 
cérébral membranes. In the cases already detailed, there are two which présent 
remarkable instances of tumours developed on the inner surface of the dura mater, 
one of them being seated in that portion of the dura mater which is in contact 
with the vault of the cranium, whilst the other was formed on one of the two 
portions of the tentorium cerebelli. Thèse * tumours had a texture analogous to 
that of the dura mater itself. One of them was constituted exclusively of fibrous 
tissue. In the other there was mixed with this fibrous tissue a certain quantity of 
ossiform matter. Both thèse anormal products bore a strong resemblance to the 
fibrous bodies of the utérus. In the two cases, the nervous substance was rather 
wasted than compressed, where it was in contact with the tumours. In one of 
thèse cases we could not refer the disease of the dura mater to any appréciable 
cause. In the other case, it was after external violence inflicted on the occipital 
région, that the tentorium cerebelli became the seat of the osteo-fibrous végétation 
already described. Here then is one of those cases wherein we must have recourse 
to the existence of a disposition altogether peculiar, in order to explain those 
infinitely varied lésions which one and the same cause is capable of producing. 

One of our cases presented us with a considérable ossification of the great fold 
of the dura mater, known by the name of the faix cerebri ; this is the part of the 
dura mater most frequently incrusted with calcareous phosphate. In two cases 
where it presented no trace of ossiform substance, this faix was transformed, for 
almost its entire extent, into a large plate of cartilaginous texture. 

The very fine cellular tissue interposed between the proper tissue of the dura 
mater, and that of the arachnoid lining its inner surface, has presented to us some 
lésions worthy of remark. First, we have found in it those cartilaginous or bony 
plates mentioned above, and we have elsewheref shown that the ossifications of 

* Thèse tumours are différent from the fungoid tumours which appear to he connected with 
the arachnoid of the dura mater ; they arise from the structure of the dura mater itself, with 
which they are intimately joined, and from which they are inséparable without tearing that 
membrane. — Bright, vol. ii. 663. 

For a highly interesting case of tetano-epileptic convulsions, where a bony déposition was 
found in the faix, as reported by Dr. James Johnson, See Medico-Chirurg. Review, April 
1835. 

t Pathological Anatomy. 



40 



CLINIQUE MÉDICALE. 



fibrous membranes are much more frequently seated in the cellular tissue, imrne- 
diately touching thèse membranes, than in their own proper tissue. 

On one occasion we found the arachnoid separated from the portion of dura 
mater corresponding to the arch of the cranium, by small dépositions of pus, 
between which the membranes appeared quite sound. Thèse dépositions were 
five in number, and existed only on the left side : each of them appeared as a 
white layer, from three to four Unes thick, interposed between the arachnoid and 
dura mater. There was at the same time sero-purulent infiltration in the sub- 
arachnoid cellular tissue of the convexity of the hémisphères. We have never 
met a case of sérum being effused between the arachnoid and dura mater. 



ARTICLE II. 

Lésions of the Arachnoid *. 

The lésions of the arachnoid, as those of other serous membranes, are principally 
referrible to its products of sécrétion. This may be modified in différent ways, 
though at the same time the arachnoid does not receive more blood than usual, 
and may not have undergone in its nutrition any appréciable modification. 

It should not be admitted that the arachnoid has been the seat of a morbid 
sécrétion, except when the product of this sécrétion is found in its cavity. Now 
this case is itself much more rare than that in which the morbid product is found 
outside the arachnoid, in the cellulo-vascular tissue constituting the pia mater- 

The morbid products found in the cavity of the arachnoid are the following : — 

1. An effusion of clear, transparent sérum. Such an effusion is very rare on the 
upper surface of the brain ; it is more common at the base, towards the occipital 
fossse. 2. An effusion of turbid, milky sérum, with purulent flocculi. We have 
seen but one instance of this sort in the great cavity of the arachnoid. 3. False 
membranes not yet organised, lining one or other of the free surfaces of the 
arachnoid. 4. False membranes of longer standing than the preceding, of serous 
organisation, extended over one or other free surface of the arachnoid. 5. Adhé- 
sions of a cellular appearance, similar to the bands of the pleurae, and extending 
from one of the free surfaces of the serous membrane to the other. There are 
some cases in which, instead of any of thèse anormal products, we have found 
nothing but remarkable dryness of the arachnoid on the surface not adhering. It 
vvould appear that in such a case there had been, during the last period of Tife, a 
suspension of the exhalation of the fluid, which ordinarily gives to this membrane 
a certain degree of polish and moisture. 

With or without thèse 'atter degrees of altérations of sécrétion, we have never 
observed in the arachnoid the least vascular injection ; neither have we ever seen 
in it either change of colour or thickening. It appeared to us that the cases wherein 
the arachnoid appeared at first view either coloured or thickened, were cases where 
there was lésion of the subjacent cellular tissue. 

Whatever be the nature of the délicate membrane lining the inner surface of 
the ventricles, this membrane présents, in the pathological state, nearly the same 

* The araclinoid and pia mater are so intimately connected as to be scarcely separable from 
each other, except at the base of the brain. .... The arachnoid of the adult in its healthy 
state is supposed to possess very little vascularity ; but its substance is so délicate, that the 
vessels of the pia mater are distinctly seen through it ; and when fluid is effused into the cel- 
lular membrane of the pia mater, some of the vessels appear evidently to lie on tbe surface of 
the fluid, as if they belonged to the arachnoid, and do not dip down between the convolutions. 
—Dr. Bright, M.R., vol. ii. p. 669. 



DISEASES OF THE ENCEPHALON. 



4 ) 



lésions as the arachnoid deveîoped around the brain, but the former are more 
frequently met with. 

It is much more common, for instance, to find sérum effused in considérable 
quantity into the ventricles than into the great cavity of the arachnoid covering 
the convexity of the hémisphères. The présence of this sérum in the ventricles 
should be considered as the resuit of a morbid process only when its quantity 
exceeds an ounce in each latéral ventricle. When it is very abundant, it raises 
the upper wall of the ventricle, and, on pressing gently with the finger, this wali 
présents a manifest fluctuation. In such case there can be no doubt but that the 
accumulation of sérum in the cérébral cavities is a morbid phenomenon. We 
seldom find any perceptible différence in the quantity of fluid contained in each 
ventricle. Whenever this quantity was very considérable, we have found the 
septum lucidum and the fornix very much softened. In some cases we have seen 
the two laminœ of the septum lucidum separated by sérum, and the cavity of the 
fifth ventricle thus become accidentally quite manifest. 

Instead of limpid sérum we occasionally meet in the ventricles a turbid liquid, 
in which are observed those flocculi, called albuminous, which constitute so fré- 
quent an anatomical character of pleuritis or peritonitis. 

In some of the cases which came before us, we have seen the ventricles filled 
with a collection of real pus, which, by reason no doubt of its greater weight, was 
found accumulated in great quantity, principally at the lower part of each latéral 
ventricle, or in the ancyroid cavity. 

In most of the cases where pus was found within the latéral ventricles, some 
was also observed at the same time in some points of the sub-arachnoid cellular 
tissue surrounding the nervous centres. 

The membrane yielding thèse varied products, once presented to our view some 
finely injected vessels, which lined as a net-work the inner surface of the parietes 
of the ventricles. In ail the other cases, in those even where pus filled the ven- 
tricular cavities, no appréciable lésion appeared in the membranes lining their 
parietes. 

We do not, in fact, consider as an altération of nutrition in this membrane, but 
as a product of morbid sécrétion, small granulations *, which are sometimes seen 
sca'tered on the inner surface of the ventricular parietes, a remarkable spécimen 
of which we observed in one of our cases. 



ARTICLE III. 

Lésions of the Pia Mater. 

Thèse have been much more frequently observed than lésion of the two other 
membranes. The lésions which this membrane has presented are the fol- 
lowing : 

1 . Infiltration of its tissue by a clear, colourless, transparent sérum. Sometimes 
this sérum forms but a thin layer interposed between the arachnoid and the céré- 
bral substance ; sometimes accumulated in more considérable quantity beneath 
the arachnoid, it raises this membrane, and distends the cérébral anfractuosities. 

2. Infiltration of the tissue of the pia mater by a turbid, milky liquid, and some- 
times by real pus f . The latter has sometimes a remarkable consistence ; it is as 

* This is a resuit of inflammation of the surface of certain parts becoming scabrous, as if 
covered with fine sand ; this appearance takes place in différent parts, and is frequently very 
manifest about the foramen of Munro, or the peduncles of the pineal gland. — Bright, vol. ii. 
692. 

f This is an undoubtcd resuit of inflammatory action, filling the meshes of the pia mater 
with a semi-fiuid substance of a colour much resembling pus ; it is not effused upon the surface 



42 



CLINIQUE MEDICALE. 



it were iiitimately combined with the cellulo-vascular tissue within which it is 
formed ; it is concrète like certain pseudo-membranes of the pleura or peritoneum. 

3. A real state of scirrhous induration of the tissue of the pia mater. We once 
saw such a state ; between the arachnoid and the circumvolutions of the cérébral 
hémisphères there was a layer of solid matter, of a bluish grey, from five to six 
lines thick. This layer existed over nearly the entire extent of the convexity of 
the two hémisphères. 

4. Serous cysts * variable in size and number. Thèse may, in proportion as they 
become developed, compress the cérébral substance more and more, and thus 
become, in a way altogether mechanical, the cause of différent phenomena. 

5. Cartilaginous, or osseous plates, which we have seen in one case cover, like a 
second arch, the anterior fourth of the convexity of one of the cérébral hémisphères. 

6. Tubercles, sometimes few in number and scattered over a broad surface, 
sometimes numerous and collected together, and forming, by their union, homo- 
geneous whitish masses, which, on the one hand, compressed the arachnoid, 
through which they were seen, and which, on the other hand, sunk deep into the 
circumvolutions, the tissue of which they compressed. In one case, where thèse 
tubercles were thus collected, the pia mater had, at the same time, contracted such 
intimate adhésions with the cérébral substance, that the latter was detached in 
large portions along with the pia mater. 

It often happens that tuberculous matter is deposited between two circumvolu- 
tions, the interval between which it perfectly fills up. It then happens that the 
two portions of pia mater, covering each circumvolution, corne to form strong 
adhésions to each other, and in such case, a cursory examination might incline us 
to think that it was in the parenchyma of the brain that the tubercular matter was 
deposited. 

4. Adhésions.— Thèse are formed between the portions of pia mater leaving the 
arachnoid in order to line the interior of an anfractuosity. Then this anfractuosity 
completely disappears, and several circumvolutions are observed as it were soldered 
together; they are so firmly united that they cannotbe separated unless bytearing 
them. 

In concluding this enumeration, let it be observed, that most of the lésions of 
which médical writers place the seat in the arachnoid, and which they consider as 
the anatomical characters of arachnitis, réside most frequently in the pia mater. In 
almost ail the cases, for instance, where the convexity of the cérébral hémisphères 
was covered with a layer of sérum or pus, this layer had its seat beneath the 
arachnoid ; on passing the back of the scalpel ove^ the latter membrane, the 
morbid product is displaced, but not removed. 

Sometimes this product is so extensively connected with the cel^ulo-vasculai 
tissue. interposed between the arachnoid and brain, that it cannot be displaced even 
by the process just now mentioned. 

Every time we found tuberculous matter deposited around the nervous centres, 
in their enveloping membranes, it was not the arachnoid that appeared to contain 
this product of morbid sécrétion ; it filled the meshes of the pia mater. We 
might say as much of the cartilaginous or bony concrétions occasionall}' found in 
the form of grains, or plates, more or less extensive, around the substance of the 
brain or spinal marrow ; here too it was the pia mater which appeared exclusively 
to be the seat of them, except in the case above noted, where thèse concrétions were 
developed between the arachnoid and dura mater. 

of the arachnoid, nor does it remain upon the surface of the brain but when the membranes 
are drawn ofF, it séparâtes with them, leaving the convolutions quite exposed, and when an 
incision is made into the membranes, none of the yellow deposit escapes — Bright, vol. ii. 674. 

* Thèse serous cysts appear to be placed between layers of serous membrane, or to be con- 
tained in adventitious membranes; they vary from the size of a pea to that of an orange; they 
are of a most chronic character, often give no symptoms by which their existence is even sus- 
pected, and are probably coeval -with life, not only the brain, but the bony parietes being 
often moulded to their form. — .Bright, vol. ii. 675. 



DISEASES OF THE ENCEPHALON. 



43 



In line, it is in the pia mater also that we find those smalJ bodies, commonly 
kuown under the name of Glandulœ Pacchioni, which, in some subjects, are found in 
great numbers towards the edge, which séparâtes the upper part of the internai 
surface of each cérébral hémisphère, but the existence of which is far from being 
constant. We think, with several other persons, that thèse bodies, so improperly 
called glands, are a morbid product formed in the pia mater, and that they should no 
more be considered as a condition of the normal state,than should those cellular bands 
in the pleura, which, in conséquence of their great frequency, some ancient authors 
have considered to be a physiological product. In fact, thèse bands have been 
designated, in old anatomical writings, by the name of ligaments of the pleura. 

If we now corne to consider simple redness, and the différent degrees of injection 
which the membranes may présent, we might still further confirai by our own 
observation what has been said by Chaussier and others ; we should find that this 
redness, more or less bright, more or less extensive, has, ninety-nine times in a 
hundred, its exclusive seat in the pia mater, and that above the latter the arachnoid 
remains transparent and colourless. 

However, whilst we admit that in the diseases designated by the name of 
arachnitis, or more properly meningitis, anatomy discovers lésions in the pia mater 
much more frequently than in the arachnoid ; still, we should not assert, as some 
writers would do, that the arachnoid always remains unafiected. If it is not yet 
clearly proved that it has been sometimes found either injected or thickened, at 
least it is certain that morbid products have been found in its cavity. We have 
adduced cases where there were effusions in the cavity of the arachnoid either of 
sérum or of pus ; we have cited others in which cellular adhésions, similar to those 
of the pleura, united the two reflections of the arachnoid to each other. 

The lésions which may exist in the pia mater, may occupy différent parts of this 
membrane. They are found more frequently in the convexity of the cérébral 
hémisphères than in any other part. When traced over this convexity, we some- 
times find them extended to the two hémisphères, sometimes they are confined to 
one. Thus, in several of our cases, we have seen the upper surface of only one 
hémisphère, of a more or less bright red colour, or covered with pus, while the 
other was pale and free from any trace of purulent infiltration, or any other lésion. 
Frequently too, it is not the entire of the upper surface of one of the hémisphères 
that is the seat of this lésion (whether injections or any other-). It may occupy 
but a more or less circumscribed portion of this surface ; and with respect to the 
différent symptoms which may resuit, it is well to remark, that there are some 
cases, where there is found either simple redness, or purulent infiltration, precisely 
limited :— lst, To the anterior extremity of one or other hémisphère. 2nd, To 
its middle portion. 3rd, To its posterior portion. 4th, To its latéral parts. The 
anterior part of the hémisphères has appeared to be the most fréquent seat of the 
partial meningitis. 

We remember to have seen some cases wherein a bright redness existed simul- 
taneously over the entire anterior extremity of each hémisphère ; everywhere 
else the pia mater remained pale. 

On the lower surface of the brain the same lésions presented themselves, but 
with more frequency, at least if we are to rely on what we have seen ourselves. 
There also the pia mater is seen diseased over a great extent of surface ; some- 
times, as in the convexity of the brain, some points only are found affected. In 
the latter case, the part where we have most frequently found purulent infiltration, 
is that which is around and posterior to the commissure of the optic nerves. 
Some pus is also observed occasionally within the fissure of Silvius. One of our 
cases presented to us the rather remarkable phenomenon of purulent infiltration, 
which existed only on one of the halves of the pons Varolii and medulla 
oblongata. 

The pia mater covering the cerebellum, appeared to us much more rarely 
affected than the pia mater of the brain. 



44 



CLINIQUE MÉDICALE. 



The pia mater of the spinal cord présents ail the changes to be found in that of 
the encephalon ; but from our own expérience, as well as that of others, we find 
that the pia mater enveloping the spinal cord is much less frequently diseased, 
than the pia mater enveioping the brain. According to our expérience also, in 
most of the cases wherein the pia mater surrounding the spinal cord has become 
the seat of purulent infiltration, this same infiltration is also found in the encephalic 
pia mater. On the contrary, nothing is more common than to find the latter con- 
siderably altered, whilst the other is perfectly sound. 

With respect to the relative frequency of the lésions of the différent parts of 
the encephalic pia mater itself, we find that the lésions of the pia mater of the 
convexity of the hémisphères, exist more frequently alone than the lésions of the 
pia mater of the base. In most of the cases where we ascertained an altération 
in the latter, we found it either in the ventricles, or on the convexity of the 
hémisphères. 

Diseases of the membrane lining the inner surface ot the ventricles, have not 
appeared to us necessarily connected with diseases of the pia mater surrounding 
the brain, either at its base or convexity. We have accordingly adduced some 
cases in which the ventricles were filled with pus, or considerably distended by 
sérum, without any appréciable lésion existing in the external pia mater, nor in 
the other parts of the arachnoid. 

Ail possible varieties of altération of the membranes may exist without the 
cérébral substance itself participating in any way with thèse altérations. In most 
of the cases reported this substance was perfectly untouched. But at other times 
we found it changed together with the méninges. Thus, in some cases where the 
inflammation was principally seated in the part of the méninges covering the 
convexity of the hémisphères, we, not rarely, find the grey substance of the cir- 
cumvolutions injected and softened ; this substance is then raised like a pulp, 
when we try to separate the pia mater from it. Sometimes we find no morbid 
altération at a greater distance down, and sometimes the entire medullary substance 
of the hémisphères présents on each slice a great number of red points, which are 
the divided orifices of so many vessels gorged with blood. 

In some cases, where the sub-arachnoid cellular tissue contained a great quantity 
of sérum, we were struck with the species of œdema, of which the cérébral 
substance was itself the seat. On slicing this substance, and pressing it between 
the fingers, a serous liquid was expressed from it similar to that infiltrating the 
pia mater*. 

Every time we found in the ventricles sérum sufficient to distend them per- 
ceptibly, so that their upper wall presented an évident fluctuation, we were struck 
with the great softening of the central white parts of the brain — namely, the 
septum lucidum and fornix. 

In one case which we have reported, and where the ventricles contained pus, 
another species of softening existed ; it was seated in the most superficial part of 
the cérébral substance which forms on the outside the wall of the latéral 
ventricles. 

In thèse différent cases, the altération of the nervous substance seems to be a 
simple complication of the lésion of the membranes. There are other cases, on 
the contrary, where it is the meningitis that complicates the affection of the 
parenchymatous substance. Thus, for instance, in certain cases of exclusive 
softening, which commence quite near the periphery of the brain, we find a 
partial meningitis, whose limits are marked by the fimits of the cérébral softening. 

* This cérébral œdema is the only altération we met in an individual, whose body we lately 
examined, and who, about fifty hours before death, had fallen suddenly, deprived of consciousness 
and motion. He died with ail the symptoms characterising a violent attack of apoplexy. This 
was serous apoplexy. 



DISEASES OF THE ENCEPHALON. 



45 



CHAPTER IL 

DISTURBANCES OF FUNCTION. 

Thèse disturbances are of two kinds : some are referrible especially to the 
fonctions of relative life, and serve in a particular manner to characterise the 
disease ; others relate to the organs of nutritive life, and though they may be less 
characteristic than the former, they are not however void of importance in 
establishing the diagnosis. We shall now pass them both in review. 



FIRST ARTICLE. 

DISTURBANCES IN THE FUNCTIONS OF RELATIVE LIFE. 
SECTION I. 

Lésions of Sensibilité/. 

Thèse lésions have as their seat, either the membranes themselves, or the dif- 
férent parts which receive nerves from the cerebro-spinal axis. 

Similar in this respect to the différent fibro-serous membranes, the méninges 
make known most of their altérations by a greater or less exaltation of their 
sensibility, whence arises pain of head, which becomes one of the most important 
sj^mptoms to be considered in the history of meningitis. W e shall first set about 
determining what is the degree of frequency of this symptom, in diseases of the 
méninges. 

Out of twenty-eight cases of affections of the cérébral méninges which we have 
reported, we find sixteen in which the headach existed, and twelve in which this 
symptom was not observed ; but in thèse twelve, there was one (case 5) in which 
the patient was not minutely watched, and another (case 1 1) in which the delirium 
having existed from the commencement, the pain of head could not be complained 
of by the patient. 

In the sixteenth case, in which the pain did exist, the altérations discovered in 
the post mortem were as follow : — 

In two of thèse cases (cases 1, 2) the patients presented after death tumours 
developed primarily in the dura mater, which had compressed the nervous sub- 
stance in contact with them. 

In two other cases (cases 3, 4) an effusion of blood existed in the greatcavity of 
the arachnoid. 

In two subjects (cases 18-21) no other altération was observed but considérable 
effusion of limpid sérum in the cérébral ventricles. 

Three other subjects (cases 6, 7, 9) presented nothing but redness of the 
méninges. 

Another (case 8) presented pseudo-membranous concrétions deposited within 
the great arachnoid cavity. 

In five post mortem examinations (cases 10, 15, 22, 24, 26) we found the pia 
mater, whether of the convexity, or of the base, infiltrated with pus. On one of 
thèse five (case 24) there were also found cellular adhésions intimately Connecting 
together the two reflexions of the arachnoid covering the convexity of the brain. 
This individual had been ail his life tormented with headach. 

In only one case (case 16) we found the ventricles filled with purulent fluid. 

From thèse facts we are warranted in concluding that the pain accompanying 
diseases of the méninges, may exist with diseases of thèse membranes widely 
differing from each other both in their nature and their seat. 



4 G 



CLINIQUE MEDICALE. 



Let us now inquire what lésions were found in the membranes in the twelve 
patients whc complained not of headach. In two of them (cases 10 and 16), the 
pia mater was infiltrated with pus, either the portion of it extended over the 
convexity of the cérébral hémisphères (case 10), or that covering the base of the 
hrain (case 16). A sero- purulent liquid filled the ventricles in the subject of 
case 19. 

From thèse facts it follows, that the diseases of the membranes, during which no 
headach was observed, differed neither in their nature nor in their seat from those 
in which pain of head was one of the symptoms. 

The following table will show the greater or less frequency of the headach in 
thèse différent cases : — 

Natur-e of the Changes. Headach. None. 

Accidentai productions developed in the dura matter 2 

Effusion of blood into the great cavity of the arachnoid, 2 

Redness of the membranes, 3 

False membranes in the cavity of the arachnoid 4 

Purulent infiltration of the pia mater, 5 2 

Pus effused into the latéral ventricles, 1 1 

Serous effusion into the pia mater extemally, and into the ventricles, 2 6 

Chronic thickening of the méninges, 1 

Out of sixty-two cases of acute inflammation of the méninges, free from any com- 
plication, described in the work of MM. Parent du Chatelet and Martinet on 
Arachnitis, there were fifty in which pain of head is mentioned as a prédominant 
symptom. Of thèse fifty, some were cases of meningitis of the convexity, and the 
others meningitis of the base or ventricles. Of fourteen cases of acute meningitis 
free from complication, published by Dance, there were twelve in whom this 
symptom was observed. In the numerous cases published by Dr. Charpentier, of 
Valenciennes, in his work on hydrocephalus acutus, pain of head was noted as a 
more or less prédominant phenomenon of tbe disease. From this résumé of facts 
it follows that, in the great majority of cases, pain of head is a symptom of acute 
or chronic diseases of the méninges, and that it may accompany the most varied 
lésions of thèse membranes, either injection of their tissue, or the formation of 
membranous concrétions on the free surface of the arachnoid, or purulent infiltra- 
tion of the pia mater, or an effusion of pus into the ventricles, or a considérable 
accumulation of sérum within thèse same ventricles. 

Can this headach serve to distinguish an inflammation of the méninges, and is 
it not also found in other diseases, which, though existing without the brain, may 
still give rise to several of the symptoms which characterise acute meningitis ? — 
To the latter, acute inflammations of the digestive tube, in particular, may be 
be referred. Out of forty-five individuals affected with inflammation of the diges- 
tive tube, whether follicular or simply erythematous, whose autopsy is detailed in 
another part of this work, twenty-ohe complained of greater or less pain of head ; 
in the remaining twenty-four this symptom was not noted ; but among the latter 
there were seven, the précise history of whose state could not be satisfactorily ascer- 
tained. Out of thirty-one cases, whose history is described in the work of MM. Petit 
and Serres on Entero-mesenteric Fever, twenty-one complained of pain of head. 
Among thirty-six patients mentioned in Professor Bouillaud's work on fevers, head- 
ach was observed in twenty-eigbt, Among fifty cases reported by M. Louis, in his 
work on Typhoid Fever, forty-four were affected with headach. From thèse cases, and 
several others published by M. Trousseau and M. Dance (in ail of which the only 
lésion found was in the digestive tube), it clearly follows that pain of head is a symp- 
tom observed in other instances than those wherein the nervous centres are prima- 
rily and idiopathically affected ; consequently it cannot be given as a proof of the 
existence of a meningeal affection. Presenting itself at the outset of several fébrile 
affections, it indicates no doubt a disturbance of the innervation ; but it no more 
establishes the proof of a real meningitis, than those pains of the limbs do, which 



DISEASES OF THE ENCEPIlALON. 



47 



are so coramon in such cases. Is it not agai-n to thèse pains, which are altogether 
nervous, and which are not connected with an inflammatory state of the organs in 
whose vicinity they are felt, that we should attribute several of the epigastralgies 
so fréquent at the commencement of fébrile diseases, and which we think are too 
often and too iightly attributed to a gastritis ? However, pain of head, though 
joined to a crowd of différent affections, may présent in cases of meningitis, certain 
distinctive characters, indicating its connexion with an inflammation of the mem- 
branes of the brain. To this matter we shall now direct our attention, considering 
this pain of head with respect to its seat, its nature, its intensity, and duration, the 
time of its appearance, and its connexions with the other symptoms. 

We have already seen that the headach is observed with equal frequency, 
whatever be the seat of the meningitis. We shall now inquire whether the seat 
of this pain of head varies with that of the affection, and whether it is possible to 
détermine exactly the point where the méninges are affected, from the part where 
the pain of head is felt. On reviewing our sixteen cases where there was head- 
ach, we find that in five of them the seat of the pain of head was not pointed out, 
or that it was stated as affecting the entire head. In the eleven other cases, it was 
limited to a part of the cranium, and was often circumscribed very exactly to that 
part. Of thèse eleven cases of headach thus circumscribed, there are six in which 
the seat of the lésion of the méninges is very precisely indicated by the seat of 
the pain. In the five other cases where, as in those already considered, the pain 
of head was circumscribed, we find no connexion between the seat of the pain and 
that of the lésion. With respect to the five cases in which we no longer find the 
pain of head circumscribed, there is but one of them in which the lésion of the 
membranes was circumscribed to one point. In the four other cases, the affection 
of the membranes was much more gênerai ; it existed over the entire convexity of 
the hémisphères in cases 3 and 1 1 ; the serous membrane of the ventricles was 
specially affected in case 20 ; and, in fine, the entire of the membrane was affected 
in case 24. 

From thèse facts we may conclude, that though in some cases the seat of the 
lésion of the membranes may be indicated by that of the pain of head, it is not 
always so. We have seen, in fact, some cases in which the meningitis is either 
much more extensive or much more limited than the seat of the headach seemed 
to announce. Oftentimes also the pain manifests itself at a distance from the place 
where the membranes are affected. Thus we have seen a simple frontal pain of 
head coincide sometimes with meningitis of the base, sometimes with meningitis 
of the ventricles. This assertion of ours is corroborated by very many cases con- 
tained in the work of MM. Parent and Martinet, as also in that of M. Dance 
on the acute hydrocephalus of adults, in which there is by no means a constant 
connexion between the seat of the pain and that of the lésion. 

If we now seek what is the seat of the headach in severe fevers, we shall find 
that, in the great majority of cases, the pain is frontal or sub-orbital ; that in some 
it is more particularly felt either at the temples, the sinciput or the occiput ; and 
that in some cases the patients cannot point out its précise seat. There are then 
some traits of resemblance, with respect to seat, between the headach which is the 
symptom of a meningitis, and that which exists in continued fever. However, we 
do not see in the latter case, as in the former, the headach so precisely confmed 
to certain points of the head. The intensity of the headach appears to merit con- 
sidérable attention, when it may be an object to convert this symptom into a sign. 
The pain of head which accompanies severe fevers is most frequently not known 
by the physician, uniess when he questions the patient on the subject, the latter 
giving but a mere secondary attention to it. In very many cases of meningitis, 
on the contrary, it is the patient who first mentions the pain of head ; and until 
he has become either delirious or comatose, this pain is to him one of the prédo- 
minant phenomena of his disorder ; it sometimes forces him even to scream aloud. 
It has not been found that the différent degrees of the intensity of the headach 



43 



CLINIQUE MEDICALE. 



depended either on the nature of the lésions of the membranes, or on their seat. 
We have found it as acute in cases where there was but simple injection of the 
pia mater, as in those where the pia mater was infiltrated with pus, or where 
a false membrane covered the arachnoid. With respect to the seat of the lésions, 
we find that, in cases where the headach was most intense, some related to 
meningitis of the convexity of the hémisphères, others to meningitis of the base of 
those hémisphères, others to inflammation of the entire membranes surrounding 
the nervous centres, others, again, to effusions of pus or sérum into the ventricles. 
Between thèse cases, and those where the pain of head was either much weaker, 
or none at ail, we do not find any différence with respect to the lésions ; and in 
order to explain so many varieties, we are always obliged to admit individual 
dispositions, which, with lésions apparently identical, produce, according to the 
subjects affected, phenomena of the most différent kind. 

The nature, also, of the pain felt by patients attacked with meningitis is not the 
same in ail. Some think that there is an enormous weight on their skull ; some 
complain of violent lancinating pain, either continued, or returning at intervais ; 
several fancy that a tight band compresses their forehead ; some say that their 
head is squeezed, as it were, in a vice. Ail motion applied to the head, or even 
to the other parts of the body, is offentimes intolérable. We have seen some 
patients whose headach was increased by slight pressure made on the integuments 
of the cranium. We never saw, on the contrary, this pressure diminish the 
headach, as so often happens in the cases of headach called nervous. The period 
when the headach appears is not the same in ail cases. Most frequently, how- 
ever, it shows itself, from the commencement, sometimes dull at flrst, and gradually 
becoming intense ; sometimes, on the contrary, attaining at once its maximum of 
severity. In several cases of our own, in very many published by MM. Parent and 
Martinet, and in nearly ail those of M. Dance, the pain of head showed itself from 
the very commencement. The cases in which headach marks the commencement 
of the disease seem divisible into two séries, according as the headach developes 
itself singly, without any other morbid phenomenon accompanying it, or according 
as its appearance coincides with that of other symptoms. The first séries includes 
the most numerous cases. The time during which the headach continues the only 
appréciable morbid phenomenon may vary from some hours to several days. 
When this headach thus précèdes the other symptoms, there are some cases in 
which it seems to have nothing serious in it. It sometimes resembles mere 
rheumatic pain ; sometimes it might .be taken for neuralgia. There are some 
individuals who, for some time, seemed to have merely a megrim more or less 
violent ; the mistake was easily fallen into in those cases where, a littl'e after the 
appearance of the headach, vomiting supervened. The second séries includes 
those cases in which the headach, still presenting itself at the commencement, is 
accompanied, from the moment of its appearance, by other symptoms, whether of 
mere fébrile commotion, or of différent disturbances of innervation. There are 
some rare cases in which the pain of head continues with great intensity during 
the entire disease ; but most frequently there are developed on the part of the 
nervous System more severe symptoms, which soon prevent it from being 
perceived or complained of by the patient. It may then be laid down that the 
pain of head generally exists only during the first period of meningitis. It is 
very uncommon to see it corne on after this period. Headach is almost the only 
modification of sensibility observed in the ordinary cases of meningitis. In some 
few of the cases reported by us the cutaneous sensibility was rendered rather 
obtuse ; but it may be remarked, that in one of them the brain itself was the seat 
of considérable pressure made by a tumour developed in the dura mater. There 
was one case, also, where the sensibility was very much exalted. From several 
cases published by MM. Parent and Martinet, and also by M. Dance, we fee\ 
warranted in laying it down, that in the meningitis of adults, modifications 
observed in the cutaneous sensibility may be considered as mere exceptions ; 



DISEASES OF THE ENCEPHALON. 



49 



when they do exist, they are to be referred to a peculiar disposition in the subject, 
and not to any spécifie lésion. 

It is but rarely that pains of any importance are observed in other parts of the 
body besides the cranium. If we compare, with respect to their nature and their 
frequency, the lésions of gênerai sensibility observed in cases of acute meningitis, 
with those seen in cases of typhoid fever, we shall find that in both thèse lésions 
scarcely differ either as to their nature or their frequency ; so that their existence 
cannot serve to establish the diagnosis between acute meningitis and severe cases 
of fever. We shall now terminate this considération of the modifications of sensi- 
bility in meningitis, by inquiring in what manner the organs of the sensés are 
disturbed in this disease, particularly those of sight and hearing. The modifica- 
tions in the organ of sight were, for a long time, noted by pathologists as capable 
of serving to characterise certain acute or chronic affections of the brain. Thèse 
modifications may be classed under the three following heads : — lst. Modifications 
of the motions of the globe of the eye ; 2nd. Modifications in the state of the 
pupil ; 3rd. Modifications of vision itself. The motions of the eye may be altered 
in several ways : sometimes they are irregular, and, as it were, convulsive ; some- 
times the globe is immoveable ; sometimes there is strabismus of either one side 
or both. Thèse différent altérations in the movements of the eye cannot be 
referred to any spécifie lésion. They have been observed in adynamic and ataxic 
fevers, without any appréciable lésion of the nervous centres. Strabismus, how- 
ever, when permanent, may be considered to possess more value as a sign of 
meningitis than the irregular movements of the globe of the eye, or its immobility. 
The state of the pupil is far from being always the same in the différent cases of 
meningitis. Several physicians consider that this opening, contracted and im- 
moveable in the first stage of the disease, becomes dilated and immoveable, as 
soon as serous or purulent effusion has taken place, either around the brain or into 
the ventricles. This rule I do not conceive to be always exact ; for with lésions 
precisely identical the pupils may présent the most différent appearance : and 
what is more, with lésions altogether dissimilar, thèse openings may présent 
precisely the same appearance. This was also long since remarked by MM. 
Parent and Martinet. We find, in their work, cases of dilatation of the two 
pupils : first, with effusion into the two latéral ventricles ; secondly, with effusion 
into only one ventricle ; thirdly, with mere serous or purulent infiltration around the 
brain (at the convexity or base) ; fourthly, without any of thèse lésions. In four 
cases where dilatation affected only one pupil, the effusion existed in the two 
ventricles. In another case, where there was also but one pupil dilated, the 
effusion took place in only one ventricle, that of the side opposite to the dilated 
pupil. With respect to contraction of the pupils, MM. Parent and Martinet cite 
cases where this contraction coincided with an effusion into the ventricles, and 
other cases in which no effusion existed. M. Guersent, the writer of the article 
Meningitis in the Dictionnaire de Medicine (21 vol. edit), admits dilatation as an 
habituai phenomenon only in the last stage of the disease ; before that period, he 
says that the pupils are sometimes dilated, and sometimes contracted. 

The resuit of my own observation, as also of an attentive considération of the 
cases published by others, is, that it would be vain to attempt to connect such or 
such a state of the pupil with any spécifie morbid altération of the membranes. 

Abstracting from the nature and seat of the lésion affecting the membranes, the 
pupils in tho6e différent affections may présent the différent states which follow : — 

1. The pupils may préserve their natural appearance. 

/ Equal dilatation. 
\ Unequal dilatation. 

2. Dilatation of the pupils . . . < Dilatation of only one. 

| Dilatation of one, and contraction of the 
v other. 

E 



50 



CLINIQUE MÉDICALE. 



f Equal, 

3. Contraction of the pupils . . I q? both 



t Of only one. 

4. Alternations of contraction and dilatation of the pupils. 

But thèse différent modifications of the pupils are also met in a number of cases, 
vvhere neither the méninges nor the brain présent any appréciable lésion after 
death. We have observed them with ail their shades in individuals labouring 
under fever. Every one knows also how, even in a state of health, the condi- 
tion of the pupil varies. And if the iris is thus subject in its movements to a 
thousand différent influences— if it be under the dominion of many other modifi- 
cations of the nervous centres, besides those which pathological anatomy shall 
ever be able to reveal to us, why place any great confidence in the signs to be 
deduced from the différent states of the pupil in order to diagnose a meningitis ? 

Vision itself is, as we have said, frequently disturbed in cases of meningeal 
affections. In some patients it is entirely lost ; in others it is perverted : thus 
diplopia has been observed in some cases ; hallucinations have been also noted ; 
some persons cannot bear the rays of light on the retina. None of thèse altéra- 
tions, however, can be said to belong peculiarly to meningitis. Very few cases 
have been recorded by médical men, in which the faculty of hearing was affected 
in meningitis. Our second case affords an example of deafhess, in which, how- 
ever, the entire lésion discovered after death was seated on the upper surface of 
one of the lobes of the cerebellum, and, consequently, at a considérable distance 
from the origin of the auditory nerves. There was then lésion of function, without 
any appréciable lésion of the organ destined to perform it. Here, however, some 
portion of the encephalic mass was found morbidly changed ; whilst, in cases of 
typhoid fever, deafness has been observed, where the examination after death 
shows this mass and its envelopes to be in the healthiest state possible, at least to 
ail appearance. 

The more we study the différent altérations of sensibility presented by 
individuals attacked by meningitis, the more satisfied we are that none of thèse 
altérations are constant, none of them necessarily connected with such or such a 
form of meningitis, and that disturbance of function is much less dépendent on 
the membrane so affected, than on the brain itself. It is this organ that produces 
thèse disturbances, and consequently they must vary in the individual cases, 
according as the brain participâtes in, and sympathises with, the irritation of its 
membranes. In this way also, may be explained the infinité variability of the 
symptoms of pericarditis ; for here too, the determining cause of the symptoms is 
not in the pericardium, but in the heart itself. What you see on the dead body 
cannot always inform you what took place during life, and pathological anatomy 
does not certainly tell us ail that is to be known with respect either to the nature, 
seat, or treatment of disease *. 

Lésions of motion. — Lésions of motion are more fréquent in meningeal affections 
than those of sensation, but they are not more constant than the latter, and they 
are entirely wanting in cases where after death the same anatomical changes are 

* When either the arachnoid or pia mater, which closely invest the b#ain, are extensively 
inflamed, the function of this organ hecomes inevitably disturbed by sympathetic irritation, 
without its parenchyma necessarily partaking of the inflammation ; or if the inflammation 
extend to the parenchyma, it is mostly confined to the superficial layer of the cortical substance. 
This is exactly the manner in which the functions of the lungs and intestines are disturbed in 
pleurisy, or peritonitis. Hence, in arachnitis or meningitis, besides headach and intense fever, 
we have an increase of the gênerai sensibility, preternatural acuteness of the external sensés, 
violent delirium, and convulsions, and finally collapse, coma, and death. Extensive inflam- 
mation of the hémisphères of the brain will be characterised by a nearly similar train of 
symptoms. In the great majority of cases, the two diseases give rise to each other, and are 
thus combined ; it is then extrcmely difficult, if not impossible, to discriminate between them. 
Cyclop. of Med., vol. i. p. 284. 



DISEASES OF THE ENCEPHALON. 



51 



found, as in the cases where thèse lésions liave existed. Lésions of motion 
observed in affections of the méninges, may be divided into two great classes ; 
in the one, the motions continue, but they are performed in a disorderJy way ; in 
the other, the motions no longer exist. The first class comprises the différent 
spasms, which are sometimes clonic, sometimes tonic. 

To clonic spasms we shall refer the disturbances of motion, which have been 
ail noted in the différent cases published on diseases of the méninges. Some 
persons présent merely a state of gênerai agitation ; they are constantly in motion, 
and rest seems to them insupportable ; they are incessantly anxious to change 
their position. In others, this agitation is confined to some particular part of the 
body ; some patients are constantly moving their arms or legs ; in some the trunk 
is alternately raised and depressed ; some constantly move the head from right to 
left, and from left to right. In thèse cases it is the will, though irregular, that 
produces the motion ; there are cases, however, where the motions are involun- 
tary ; thus, in some patients, the muscles which terminate at the flexor tendons of 
the fingers, are agitated by violent contractions ; hence subsultus tendinum ; 
several présent, as a prominent symptom, a tremor which is sometimes gênerai, 
and sometimes partial. Convulsions, properly so called, are among the most 
common phenomena accompanying acute meningitis. Thèse are sometimes, 
though very rarely, gênerai. When partial, they are sometimes confined to the 
same part, at other times they affect différent parts of the body successively. 
The parts most usually affected with convulsive motions in meningitis are, the 
globes of the eyes, the eye-lids, the face, the lips, and finally the extremities. 
Tonic spasms, as they are called, are not less fréquent than clonic, in the disease 
now under considération. Thus permanent flexion of the fore-arm on the arm is 
often observed. Rétroversion of the head, its inclination to the right or left, are 
sometimes observed in cases of meningitis, as also tétanie rigidity of the neck, 
trunk, dt extremities, trismus, &c. 

Under the second class, in which motion is diminished, or altogether destroyed, 
may be reckoned those numerous varieties of paralysis observed in meningitis. 
This paralysis may affect the muscles of the eye, of the eye-lids, face, lips, or 
limbs : either one, or several of thèse, may be deprived of motion. In thèse 
différent parts the paralysis may be established either slowly, or as instantaneously 
as the loss of motion succeeding cérébral hemorrhage. The paralysis may super- 
vene from the commencement, or succeed one of the forms of spasms already 
mentioned ; it may alternate with thèse spasms ; it may, in fine, co-exist with them, 
and we have witnessed more than once one of the upper extremities completely 
deprived of motion, whilst the other was more or less violently convulsed. There 
are also some cases in which the paralysis appears and disappears by turns ; a 
phenomenon which will not surprise us, when we have seen, that in meningitis 
paralysis can exist only when there is compression of the brain. Simple hypersemia of 
the pia mater, slight purulent infiltration of this membrane, are capable of producing 
it, or, to speak more accurately, are capable of producing in the brain that modifi- 
cation, inappréciable after death, which gives rise to it. After having considered 
in a manner purely nosological the différent lésions of motion affecting those 
attacked with meningitis, we shall now try to establish some relations between 
thèse lésions, and the différent changes found in the méninges after death. For 
this purpose we shall pass in review each of the disturbances of loco-motive action 
already alluded to, first mentioning the cases only, where such disturbance existed 
singly at the last period of life. Ist. With respect to gênerai agitation, none of 
our cases presented this symptom single. MM. Parent and Martinet mention 
one case of it, in which the pia mater extended over the upper surface of the brain 
and cerebellum was infiltrated with pus. In another case mentioned by the same 
authors, in which this lésion was observed, the méninges extended over the con- 
vexity of the left hémisphère of the brain were found red and thickened. 2nd. 

e 2 



52 



CLINIQUE MÉDICALE. 



Partial agitation. We have not met one instance of this symptom uncombined 
with other lésions of motion. MM. Parent and Martinet mention a case in which 
there was observed a continuai balancing of the head to the right and left : this 
occurred the day before the patient died. The membranes covering the upper 
surface of the cerebrum and cerebellum were opaque, very red, and thickened. 
The tissue of the cerebrum, cerebellum and spinal cord were remarkably dense. 
Thèse same writers mention a case in which there was a continuai moving of the 
lower jaw, similar to that of mastication. In this the pia mater of the convexity 
was infiltrated with pus. 3rd. Subsultus tendinum. Neither has any case occurred 
to us in which this symptom presented itself singly. MM. Parent and Martinet, 
however, record four cases, in which it was the only disturbance of the loco-motive 
functions. In one of thèse cases the méninges were red and thickened nearly 
throughout their entire extent. In the three others they were infiltrated with 
pus, either at the convexity, or towards the base ; and in two of thèse three cases, 
the ventricles contained either a serous or a purulent liquid, with a granulated 
state of the membrane lining their parietes. 4th. Trembling ofthe limbs. We 
have not met any case of this occurring singly : but very few cases of it have been 
mentioned by others ; and where it did occur, no particular morbid change was 
discovered after death on which it could appear to dépend. 5th. Convulsive 
movements. Thèse are observed principally in children. Five instances have 
been recorded in the work of MM. Parent and Martinet of their occurring in 
adults — in four of thèse there were convulsive movements of the eye-lids, face, 
lower jaw and extremities. In three of thèse four there was found purulent 
infiltration of the méninges of the convexity of the hémisphères ; the fourth pre- 
sented a membranous concrétion, extended over the right hémisphère, and two 
ounces of sérum in the right latéral ventricle. 6th. Grinding of the teeth. We 
have no account of this phenomenon having occurred singly in cases of meningitis. 
7th. Permanent flexion (contracture) of the limbs. In the one case in which this 
was observed, we found considérable redness of the pia mater extended over the 
convexity of the left hémisphère of the brain, with injection of the grey substance 
of the circumvolutions of this side. In the case of a young girl mentioned by Parent 
and Martinet, who, during the five days previous to her death, presented per- 
manent flexion of the two arms, there was found gênerai inflammation of the 
arachnoid of the convexity. The méninges at the base were thickened, and a 
small quantity of pus infiltrated them towards the cerebellum. The ventricles 
were filled by a turbid sérum. 8th. Tétanie rigidity, In a considérable number 
of cases where the prevailing phenomena are rigidity of the limbs, tétanie shocks 
of différent parts of the body, tétanie curving of the trunk to the right or left, 
trismus, permanent rétroversion of the head, the lésions found after death do not 
differ in their nature from those just mentioned. Thus we observe différent parts 
of the pia mater more or less injected, purulent infiltration of this membrane, 
serous or purulent effusions into the ventricles. 

In nineteen cases in which rétroversion of the head was observed, this pheno- 
menon coincided once with a lésion of the méninges of the convexity and base ; 
twice with lésion of the méninges ofthe convexity, base, and that of the ventricles ; 
three times with simple lésion of the méninges of the convexity, three times with 
lésion of the ventricular membrane, five times with lésion of the méninges of the 
base, and five times with lésion of the méninges of the base and ventricles. 

In fifteen cases where tétanie rigidity was one of the prevailing phenomena, 
whether gênerai, or limited to some part, as to the neck, trunk, extremities, jaw, 
the lésions, with respect to their seat, were as follow :— 

Lésions of the méninges of the convexity - - three times. 

of the base - - three times. 

of the ventricles - • - three times. 

of the base and ventri^^ - - four times. 

of the entire méninges - - twice. 



DISEASES OF THE ENCEPHALON. 



53 



9th. Paralysis. In the fifteen cases of hemiplegia already mentioned, the follow- 
ing altérations were seen : in four the brain was compressée! by accidentai pro- 
ductions developed in the méninges, which compression constantly occurred on 
the side opposite to that of the hemiplegia, and was made from above downwards. 
In rive of thèse cases the compression was confined to one of the cérébral hémi- 
sphères ; in one only (case 2) a tumour appertaining to the dura mater had com- 
pressed and wasted one of the lobes of the cerebellum. In this last case also the 
paralysis was crossed, just as in those cases where the lésion was seated in the 
cérébral Hémisphères, and nothing else was observed but simple hemiplegia, with- 
out any other modification of motility. However, before the hemiplegia was 
established, convulsive movements had taken place in the arm of the side opposite 
to that of the lésion of the cerebellum ; afterwards this limb ceased to have the 
power of motion ; and subsequently the paralysis extended to the lower extremity 
of the same side. In the subject of our first case, the hemiplegia was established 
gradually without being preceded by any convulsive movement. There was in 
this case pressure made on one of the cérébral hémisphères by a fibrous végétation 
of the dura mater. In our fourth case the extremities of the right side were 
both gradually paralysed ; the fore-arm continued a considérable time flexed on 
the arm, but this flexion ceased at a subséquent period. Blood was found effused 
on the left side between the arachnoid and dura mater. In one of our cases, where 
a serous cyst, developed in the pia mater of the convexity, had preceptibly de- 
pressed the circumvolutions, the patient had a hemiplegia of very long standing, 
with atrophy of the paralysed limbs. In six other cases, observed partly by our- 
selves, and some by MM. Parent and Martinet, this hemiplegia was seen to 
coïncide with the présence of a thick laver of pus which filled the pia mater of the 
convexity of the cérébral hémisphères. 

Of thèse six cases there were three, in which, though there was hemiplegia, an 
equal quantity of pus was efFused over the two hémisphères, and three others, in 
which the pus was collected only in the hémisphère of the side opposite to that 
where the paralysis took place. At first sight, the proportion here seems 
equal, but a more attentive examination will alter it entirely ; for, in one case, at 
the same time that the pia mater of the convexity of the two hémisphères was 
iufiltrated with pus, the substance of the brain (the left hémisphère), on the level 
of, and external to, the ancyroid cavity, contained a tubercle, which may be fairly 
considered to have caused the hemiplegia, more particularly as the latter 
affected the right side, and had come on progressively. In another of thèse cases, 
in addition to the purulent infiltration of the entire pia mater, on opening the 
body, the inner table of the frontal bone was found a little depressed, and making 
slight pressure on the brain. Besides, the effusion of pus, which had taken place 
over the two hémisphères, extended to the base of the cranium on the side opposite 
to that where the paralysis had taken place. There remains then but one case in 
which the paralysis having occurred on the left side, the entire pia mater was 
found infiltrated with pus, without any other complication, and even in this case, 
it was said, that towards the base the pus was more particularly accumulated on 
the right side. Thus, in thèse six cases of hemiplegia, with effusion of pus around 
the encephalic mass, there is not, in reality, one, in which the lésion was not 
greater on the side opposite to that of the paralysis. 

Of thèse fifteen cases of hemiplegia already mentioned, there remain five in 
which the principal lésion existed within the ventricles, and of thèse five there 
were two, in which both the latéral ventricles were equally affected ; in the three 
others, the only, or principal lésion, existed in the ventricle opposite to the side of 
the paralysis. In one of the above two, each latéral ventricle contained four 
ounces of iirnpid sérum ; the hemiplegia was on the right side, and seemed to have 
existed previous to the effusion. In one of the above five cases, the ventricles 
were distended by a considérable quantity of sérum ; there was also at the base 



54 



CLINIQUE MÉDICALE. 



of the brain a pseudo-membranous exudation, and the central white parts were 
softened. What was remarkable in this case is, that the paralysis which existed 
on the left side was but transient. The patient, at first, presented some rigidity 
of the fore-arra ; slight rétroversion of the head ; convulsive movements of the 
eyes, and strabismus ; then the right commissure of the lips was dragged ; the 
extremities on the left side fell into a state of paralytic relaxation, whilst those of 
the right side retained motion and sensation ; subsequently the mouth became 
straight, and the left extremities recovered their power of motion. In the fifth of 
thèse cases reported by MM. Parent and Martinet, and which they borrowed 
from Morgagni, the left ventricle was fîlled with pus, without there existing, either 
in the brain or its appendages, any other appréciable lésion. During life, the 
power of motion was destroyed over the right side of the body. 

In a case reported by M. Dance, sérum was found in the two ventricles ; but in 
the right there were but three ounces, and in the left five ; the membrane lining 
the parietes of thèse ventricles was also perceptibly thickened. A paralysis, 
which went on gradually increasing, affected the extremities of the right side, and 
the face on the same side. The extremities of the left side presented some tétanie 
twitches. The nature of the phenomena here seems to have been determined by 
the inequality of pressure made on each cérébral hémisphère, by the liquid con- 
tained in its ventricle. Instead of hemiplegia, some cases occur in which there is 
paralysis of only one limb. Thus, in one case where the pia mater, traversed by 
tubercular granulations, was infiltrated with sérum towards the convexity of the 
brain, the right arm, as well as the right side of the face, were the only parts 
affected with paralysis. In case 25, where pus infiltrated the pia mater of the 
convexity, and filled the ventricles, we witnessed, on the one hand, paralysis of the 
right arm, and on the other hand, paralysis of the left eye-lid, which was depressed 
over the eye ; as also of the left cheek, which became passively distended at each 
expiration. In thèse two cases the brain was exposed, on both sides, to equal 
pressure ; yet, why do we find effects so différent on the two sides of the body ? 
MM. Parent and Martinet relate a case where there were observed, alternately, 
and within a short space of time, at first convulsive movements of the left arm, 
then paralysis of the right arm, then convulsions in this same right arm ; and at 
the same time that thèse convulsions exist, the right side of the face was struck 
with paralysis. What do we find, however, on opening the body ? Pus over the 
entire convexity of the brain, only being more abundant on the right. In the 
numerous cases, where some parts, as one side of the lips, oj one of the eye-lids, 
are the only parts paralysed, we find lésions of the same nature and the same 
extent as in the preceding cases. The parts of the nervous centres which give 
origin to the nerves of the eye-lids and lips, présent no appréciable lésion, and the 
pia mater is found either injected or filled with pus, as in the cases where complète 
hemiplegia existed. 

We shall now consider those cases in which the loss of motion, instead of being 
confined to any particular part, is, on the contrary, gênerai, and affects, either 
successively or simultaneously, the two sides of the body. In ail the cases of this 
kind which have occurred to us, wlïen the paralysis of both sides came on before 
the final struggle, we found, on both sid'es of the brain, lésions corresponding to 
this symptom. 

The différent facts which have now been analysed, with the view of discovering 
what are the lésions, which, in cases of meningitis, coincide with the différent 
altérations in the power of motion, lead us to a singular conclusion, namely, — that 
with similar lésions of structure in the dead body, the most varied disturbances in 
the function of motion are found to coincide ; in the greater number of cases, 
whether there has been convulsion or paralysis, the structural lésion after death 
will be the same. Thus, beyond that lésion which the scalpel points out as 
having its seat in the membranes of the brain, there is, in the brain itself, a modi- 



DISEASES OF THE ENCEPHALON. 



55 



fication, not recognisable by the anatomist, which is produced to be sure by the 
lésion of the membrane, but which, "variable in each individual, is the real cause of 
ail the functional disturbances which are seen to supervene. 

The différent disturbances in the function of motion now passed in review, may 
take place also in several other cases, where, the membranes being uninjured, the 
cérébral substance itself is altered. They may develop themselves in those 
diseases known under the name of fevers, the seat of which, we are so often led by the 
symptoms to place in the brain. In fevers, as in acute meningitis, we often observe 
subsultus tendinum, convulsive motions, oftentimes partial, very seldom gênerai, 
trismus, tétanie affections of the trunk or extremities, permanent flexion of thèse 
same extremities, rigidity and paralysis of them, as well as that of the eye-lids and 
lips, trembling of certain muscles, grinding of the teeth. But in the great majority 
of cases, thèse phenomena are less fréquent, less intense, and less durable. Their 
existence, however, proves that this same modification, produced in the brain by 
the irritation of tne membranes, may also be produced in it under the influence of 
other causes, and that, without there being found, after death, any appréciable altér- 
ation, either in its substance or in the membranes which envelop it*. 

* Mr. Lallemand speaks somewhat decidedly regarding the feasibility of distinguishing 
arachnitis from inflammation of the substance of the brain by means of the symptoms con- 
nected with lésion of the functions of the muscular System ; after premising tbat thèse symp- 
toms présent themselves under two opposite forms, with increase or diminution of action, 
with phenomena of irritation or of prostration, and having stated that both forms of action 
are common to arachnitis and encephalitis, he then says — " You see, by thèse cases, that the 
spasmodic contractions of the muscles may be produced by an arachnitis, and we shall see 
presently that attacks of epilepsy, contractions of the limbs, convulsive movements, subsultus 
tendinum, are the ordinary symptoms of affections of this membrane. You must not, how- 
ever infer from this, that the arachnoid has a direct influence on the muscles. When this 
membrane is inflamed, the brain is irritated by the vicinity of the inflammation, its functions 
are exalted, and consequently those of the nervous System which are dépendent on it, there- 
fore also those of the muscular System; thence, convulsive movements, &c. : but as the 
tissue of the brain is not touched, thèse spasmodic symptoms are neither accompanied nor 
followed by paralysis. Thus, though they are sometimes observed at the commencement of 
inflammations of the brain, they are not sufficient to characterise this disease. But you will 
remark, that at this period the brain is as yet only irritated, as in cases of arachnitis, its 
tissue not being yet altered; it is not surprising, therefore, that the symptoms should be the 
same. However, it would be possible even now to distinguish them by this means : when 
they are produced by the affection of the arachnoid, they usually manifest themselves on the 
two sides of the body, whilst, when they dépend on inflammation of the brain, they most 
frequently affect only one side. Besides, they cannot be confounded long : for in the latter 
case they are soon aecompanied by symptoms of paralysis, and very frequently even there is 
observed from the commencement, the most singular mixture of paralysis and spasmodic 
phenomena." Lettre ii. p. 251; and at p. 277, he says: — " To sum up, the affec- 
tions of the brain, and those of the arachnoid by their influence on the functions of the 
brain, manifest themselves externally by the lésion of the same functions, that is to say, by 
symptoms which are related to the perception of the impressions made by external agents, to 
in elligence, and to voluntary motion. The symptoms of inflammation of the brain présent 
two characters entirely opposite ; those of irritation, and those of collapse. On the one hand, 
exaltation of the intellectual faculties, headach, sensibility of the retina, contraction of the 
pupil, pains of the limbs, continued or intermittent contraction of the muscles : on the other 
hand, diminution of intelligence, stupor, somnolence, deafness, loss of sight and of speech, 
paralysis of the muscles, insensibility of the skin. The former set of symptoms are also 
observed in inflammation of the arachnoid, and the second in apoplexy. But it is only in 
inflammation of the brain that they are found combined, because in the former case there is 
irritation of the brain without altération of its tissue ; in the second there is, from the first, 
altération without irritation : it is only in inflammation of the brain that there can be succes- 
sively irritation and disorganisation. When the paralysis précèdes the spasmodic symptoms, 
it is, that the altération of tissue précèdes the inflammation; that is to say, there is from the 
first effusion of blood. Finally, when the spasmodic symptoms are wanting, the slow and 
progressive course of the paralysis will easily render it distinguishable from that which is 
produced by apoplexy. Thus then in inflammation of the arachnoid we have spasmodic 
symptoms without paralysis ; in apoplexy, sudden paralysis, without spasmodic symp- 
toms ; in inflammation of the brain, spasmodic symptoms, slow and progressive paralysis, 
unequal and intermitting course." 



56 



CLINIQUE MEDICALE. 



ARTICLE III. 

Lésions of Intelligence. 

The intellectual faculties were found altered in the great majority of the cases 
which we have reported, as may be seen by referring to them. In fifty-four cases 
of acute meningitis affecting adults. reported by MM. Parent and Martinet, there 
were only two in which the intellects were not disturbed ; whence, we may lay it 
down, that lésion of intellect is a rauch more constant phenomenon in acute 
meningitis, than that either of sensation or motion. Such lésion may présent itself 
under two différent forms in this disease, either under the form of delirium or that 
of coma. The delirium may présent the greatest varieties with respect to its 
nature ; in somè it is very violent, accompanied with loud cries, and a great 
development of muscular strength. In others, on the contrary, it is of a silent 
description, and the patients appear very much prostrated in strength. Sometimes 
one single idea engages the mind of the patient ; sometimes ideas of the most 
heterogeneous description occupy his thoughts. In some, this disturbance of 
intellect attains its highest degree from the very commencement ; in others it 
cornes on gradually and insensibly. On reviewing, in each case, the numerous 
varieties of form which the delirium presented, we might arrive at this important 
conclusion ; — that no single one of thèse various forms characterises meningitis, 
that there is not one of them which may not be found in the différent cérébral 
irritations which are purely sympathetic, and unaccompanied with any structural 
altération of the membranes appréciable on the dead body. 

When once the delirium has developed itself, it may not cease, presenting 
merely alternations of exacerbation and remission ; it may also be only transitory. 
There are some patients in whom this disturbance of the intellectual faculties is 
but of very short duration ; then, at the end of a period, more or less long, it 
returns ; the intermissions become more and more short, and, at last, the disturb- 
ance becomes continued. In some, the delirium commences only at night, and 
the clearness of the intellect during the day seems, at first, to exclude the idea of 
a meningitis altogether. In some, a delirium of several days' duration suddenly 
disappears a little before death, when the other symptoms become more aggravated. 
Wherefore, when it is attempted to distinguish the delirium produced by menin- 
gitis from the delirium produced by sympathetic irritation of the brain, it is 
wrong to lay it down that the latter only can be intermittent, as numerous cases 
prove, beyond ail doubt, that delirium arising from meningitis may be accom- 
panied with perfectly lucid intervais. The period of the disease at which the 
delirium appears, is far from being the same in every case. Very rarely this 
phenomenon marks the outset of the malady ; so that, in the midst of health, when 
delirium does suddenly come on, it is not at ail probable that it is dépendent on 
meningitis. In the great majority of cases, pain of head précèdes it ; and often- 
times six, eight, twelve, and even fifteen and twenty days pass on between the 
period at which the pai-n of head présents itself, and that at which the intelligence 
commences to be disturbed. 

Out of forty cases of acute meningitis which fell either under our own view, 
or under that of others, in which we were certain on the one side of the précise 
time of the invasion of the disease, and on the other hand of the moment at which 
the intelligence began to be disturbed, we found the delirium to develop itself 



Ist day 


- 3 times. 


7th day 


- 4 times. 


13th day - 


4 times. 


2nd 


- 1 


8th 


- 6 


14th 


1 


3rd 


- 3 


9th 


- 2 


15th 


2 


4th 


- 3 


lOth 


■ 


16th 




5th 


- 3 


llth 


- 


20th 


2 


6th 


- 3 


12th 


- 1 


24 th 


1 



DISEASES OF THE ENCEPHALON. 57 

Sînce, with very few exceptions, delirium presented itself as a constant pheno- 
menon in acute meningitis, we must conclude that it may be produced in this 
disease, whatever be the nature of the lésion of which the membranes are the seat. 
Ail the lésions, in fact, observed in our several individual cases were accompanied 
with delirium. It is certainly curious to see a mere sanguineous congestion of 
the pia mater, even in cases where it is partial, a little pus infiltrating its 
meshes, produce the most serious disturbance in the intellects, whilst a much 
more deeply seated altération of the brain, an extensive softening for instance, 
often exists without giving rise to the slightest disturbance of the intellectual 
faculties. Is it, as has been said, because the irritation of the membranes 
reacts principally on the most superficial parts of the cérébral circumvolutions, 
and that the intelligence is chiefly seated there * ? 

We shall next consider, whether for the production of delirium it is a matter 
of indifférence what part of the méninges be affected. In this inquiry we can 
take into account those cases only in which the delirium continuée! to the 
end, single, and without being followed by coma. We have met but twenty- 
eight cases of this kind occurring either in our own expérience, or recorded 
by others. In thèse twenty-eight cases, the lésion existed 

On the upper surface of the two cérébral hémisphères - 14 times. 

On the upper surface of only one hémisphère - - 15 

On the upper surface of the two hémisphères and at the base - 3 
On the upper surface of the two hémisphères, at the base, and in 

the ventricles 4 

At the base alone - 

In the ventricles alone - - -__„__ 2 

Thus in thèse cases there are nineteen in which the lésion was limited to the 
convexity of the hémisphères, and only two in which the delirium persisted until 
death without there being a lésion of the méninges extended over the upper surface 
of the brain. 

Instead of delirium, patients labouring under acute meningitis may présent a 
state of coma, which sometimes exists from the commencement of the disease, and 
sometimes cornes on only after delirium. This second case is much more fréquent 
than the first, at least in adults. 

When a patient dies in the midst of a state of coma, the lésions found in the 
méninges differ neither in their nature nor seat from those found in cases where 
life is terminated in the midst of a state of delirium. But then are thèse 
lésions différent as to their seat ? To solve this question, we shall take a 
review of the facts as they have been observed. 

Out of sixty-one cases, in which death supervened in the midst of a comatose 

* On the subject of delirium, as connected with arachnitis, Lallernand makes the following 
remarks : — "Delirium is in gênerai regarded as a symptom of imflammation of the brain ; its 
absence might induce one to doubt of the inflammatory nature of softening of the brain. But 
it is, on the contrary, a stronger reason for this opinion ; it will be no difficult matter satis- 
factorily to prove that delirium is never observed in inflammations of the brain which are 
exempt from complication, that this symptom belongs specially to inflammations of the arach- 
noid, that persons have been led into error by the very numerous cases in which the affection 
of the arachnoid preceded that of the brain. I admit that it seemed natural to attribute the 
delirium to inflammation of the brain, rather than to that of the arachnoid ; but stnl an error 
was committed. Do mot, however, suppose that I would rnake the arachnoid the seat of the 
delirium ; every symptom is the altération of a function, and cannot be produced but by 
the organ which executed this function ; but I have already said that the affections of 
the arachnoid influence the function s of the brain in the same manner as the affections 
of the pleura influence the functions of the lung. It is impossible that the arachnoid 
should be inflamed without the surface of the brain in contact with it being also affected ; but 
its tissue not being altered, there nierely results from this vicinity an exaltation in its functions.'" 
—Lettre 2. p. 246. 



58 



CLINIQUE MÉDICALE. 



state, which existed either for several days with or without preceding delirium, or 
at îeast for twenty-four hours, we found the lésion to exist 

On the upper surface of the two cérébral hémisphères - -11 times. 

On the upper surface of but one hémisphère - 6 

On the upper surface of the two hémisphères and at the base - 5 

On the upper surface of the two hémisphères and in the ventricles 1 3 
On the upper surface of the two hémisphères, at their base, and 

in the ventricles - - - - - - 8 

In the latéral ventricles - 9 

At the base of the brain 4 

Hence it follows that coma may corne on at the différent periods of acute menin- 
gitis, whatever be the part of the méninges affected. We cannot, therefore, lay it 
down with some authors that delirium appertains exclusively to meningitis of the 
convexity, and that coma is peculiar to meningitis of the base. We think that, 
whatever be its seat, meningeal inflammation may have the effect of determining 
in the brain at first a period of excitement announced by delirium, then a period 
of collapse, either real or apparent, which is manifested by coma. In the great 
majority of cases which terminate in death, thèse two periods exist. However, in 
some instances, the period of excitement continues beyond the usual time, and such 
persons die before the coma has arrived. In others, on the contrary, the signs of 
excitement are very transient, scarcely ever apparent, and the state of coma 
déclares itself, without having been preceded by delirium, properly so called. 
There are, in fine» some cases in which the coma is the first symptom ; individuals 
who a little before were in a good state of health, fall down suddenly deprived of 
consciousness, sensation and motion. Our 20th and 21st cases présent examples 
of this apoplectic form of the disease. In the two individuals who form the 
subject of them, nothing else was found, but an enormous distension of the ventri- 
cles by îimpid sérum. Does this form, which differs from ail the others, belong 
exclusively to acute dropsy of the ventricles ? It is possible that the mere effusion 
of sérum around the brain, which infiltrâtes the pia mater, and suddenly compresses 
the nervous mass, may also produce this apoplectic form ; but in ail the cases oi 
this kind hitherto observed, the ventricles were the principal seat of the effusion. 
To the cases already cited, we might add another recently published by Dr. 
Martin Soion ; it was that of an old man, seventy-six years of âge, labouring under 
organic disease of the heart. The dropsy symptomatic of this affection had 
gradually disappeared, and the patient appeared to be doing very well. He got 
up one morning out of bed to go to the water closet — returned quickly to his room 
with his face much flushed, endeavoured to make towards his bed, when he fell 
down suddenly, and expired without uttering a word. On opening the body, the 
sinuses were found gorged with blood, the surface of the brain pale, the arachnoid 
transparent, not thickened, raised by a serous, Iimpid, colourless liquid, which infil- 
trated the pia mater, and might be estimated at about five or six ounces. The 
latéral ventricles were also found filled with a sérum equally Iimpid and trans- 
parent ; neither their parietes, nor the central white parts presented any softening. 
In the chest was discovered an organic affection of the heart, namely dilatation of 
its cavities, a thinness of its walls, and a cartilaginous state of the tricuspid valve. 

Thus, then, in proportion to the greater or iess rapidity with which a serous 
effusion takes place, whether simultaneously into the ventricles or around the 
brain, or solely within the ventricles, very différent forms of disease may présent 
themselves. If in a very short space of time, a very large quantity of sérum has 
been exhaled by the arachnoid, the resuit may be a morbid state similar to that 
which is produced by a very large cérébral hemorrhage, in other words, apoplexy. 
This is serous apoplexy, an affection which we consider the modems have been 
very wrong in erasing from their nosological Systems. — (See Case 20.) If the 



DISEASES OF THE ENCEPHALON. 



59 



sérum accumulate somewhat less rapidly, either in the external pia mater, or in the 
ventricles, the symptoms are then observed to be such as accompany every 
irritation of the méninges. — (See case 19.) If the accumulation of sérum takes 
place slowly, there may resuït a third form, of which we have an example in 
case 21. Hère the power of motion remains unimpaired, whilst the intelligence 
becomes weakened only by degrees. 

To conclude : in those cases where the disturbance of the intelligence dépends 
on an affection of the méninges, the cause of this disturbance can no more be 
referred to any spécifie altération, than that of motion or sensation can, and the 
diversity of the lésions of intelligence, as well as of those of sensation and motion, 
can only be accounted for by referring it to the différent susceptibility of the 
brain to impressions. 



CHAPTER III. 



DISTURBANCE S OF THE FUNCTIONS OF THE ORGANS OF NUTRITIVE LIFE. 

Several of thèse disturbances are very important to be considered, when we 
wish to establish the diagnosis of meningitis, and to distinguish it from other dis- 
eases in which nearly the same functional disturbances of the brain are observed. 
On the part of the digestive organs, for instance, there appear in a great number 
of individuals attacked with acute meningitis very remarkable morbid phenomena, 
which supervene, but much more rarely in cases where the intestine is the seat of 
inflammation more or less intense. The circulation is also disturbed in certain 
cases in so particular a way that, by combining the signs furnished by it with the 
signs afforded by the disturbance of the cérébral functions, we may be able to 
attain with certainty the diagnosis of meningitis. 



ARTICLE I. 

Lésions of the functions of the digestive apparatus. 

In a considérable number of individuals attacked with meningitis, the digestive 
tube does not présent during life any appréciable functional lésion. In others it is 
the seat of disturbances more or less severe ; in this latter case, it is an object to 
inquire whether thèse disturbances are merely the resuit of an anormal influence 
exercised by the nervous centres on the digestive passages, or whether they are 
connected with an affection of thèse same passages, which affection has compli- 
cated the disease of the encephalic membranes. 

When the meningitis was not complicated with any other affection, we found 
the tongue always to préserve its natural state : it is broad, moist, free from any 
redness, and sometimes even paler than usual : most frequently it is covered with 
a light white coating. This was the resuit of the analysis of thirty-seven cases, in 
which the state of the tongue was carefully noted. Among thèse thirty-seven, 
there were twenty-four in whom the tongue preserved the state above-mentioned 
during the entire course of the disease. Now, of thèse twenty-four cases, sixteen 
of which came under our own observation, and the rest under that of.M. Dance, 
we find. there were fourteen in whom the stomach presented nothing unnatural 



60 



CLINIQUE MEDICALE. 



after death, the reraainder of the digestive canal also being perfectly sound, with 
the exception of case 7th, where the lésion found was on the décline, and was 
connected with a disease, the symptoms of which ceased to exist several days 
before death. — (See the remarks subjoined to this case.) — There remain ten then 
in which. the tongue having preserved its natural appearance till death, tne stomach, 
however, did not appear to be in its physiological state. But the lésions presented 
by it were such as, under ordinary circumstances, do not exercise uny influence on 
the state of the tongue, 

We shall now consider the thirteen cases in which the tongue lost its natural 
appearance. It was then red, dry, cleft, brown, encrusted or covered with a mucous 
coat, much thicker than thë thin white coat already mentioned, which cannot in 
our opinion be considered a morbid state of the tongue. Now, of thèse thirteen 
cases there was not one which presented the gastric or intestinal mucous membrane 
entirely exempt from lésion. Sometimes this lésion was of a serious character, 
and of that class of lésion which usually coincides with a modification in the state 
of the tongue ; sometimes, on the contrary, the lésions found in the stomach were 
of a description similar to that of the lésions which we have already seen to coin- 
cide with a natural state of the tongue. It may be here remarked that acute 
inflammations of the bladder oftentimes modify very perceptibly the state of the 
tongue. — (See case 17.) 

In recapitulation it may be asserted that every time when, in an individual who 
has died of an affection of the méninges, we found on examination no morbid state 
either of the digestive or urinary passages, the tongue never lost for one instant 
its natural state ; it also preserved it in several cases where the lésions found in 
the stomach were of the nature of those which most frequently do not modify the 
state of the tongue ; and, in fine, the tongue has scarcely ever lost its physiological 
state, except in cases where the necropsy pointed out disturbances which are 
known to coincide ordinarily with a modification, more or less perceptible, of the 
state of the tongue. Every time then that, in a patient who exhibits several of 
the signs of encephalic irritation, the tongue shall be found red, dry, brown, &c., 
we shall be disposed to consider either that this irritation is but the sympathie 
product of another disease, or else that the latter complicates it*. Thus, among 
the numerous causes which may modify the state of the tongue, we must not con- 
sider inflammation of the méninges. But during its progress, or simultaneously 
with it, différent morbid states may be developed, which may or may not be appre- 
ciated by morbid anatomy, which may bring on with them a modification in the 
natural state of the tongue. 

In most of the cases where meningitis was not complicated with any affection, 
the thirst did not seem to us to be very great. The loss of appetite oftentimes 
mamfested itself at the onset of the disease ; yet in some cases the appetite still 
remained, even when the intense headach so frequently marking the commence- 
ment of the disease, already existed for several days. 

In some cases the epigastrium was the seat of pain sufficiently acute to be 
increased by pressure, and we have not seen in any of the cases where this pain 
existed that there was a complication of gastritis. This pain in the epigastrium 
manifested itself in most cases at a period not far removed from the commence- 
ment of the malady. We never observed it to become very intense, nor is it to 
be compared in this respect to the pain of head. 

We are now come to one of the phenomena which best characterise certain 
cases of meningitis, we mean vomiting and nausea. Here, as in several other 
* As there is no rule without an exception, we may state here, that in some cases reported 
in the fourth volume of this work, where the prevailing symptoms were those of ataœic fever, 
the natural appearance of the tongue might incline one to believe in the existence of menin- 
gitis ; and still such was not the case, and the entire disturbance, that at least which anatomy 
could appreciate, was seated in the intestine. 



DISEASES OF THE ENCEPHALON. 



61 



circumstances, the stornach is the seat of the phenomenon ; but its cause is else- 
where. Vomiting, or at least nausea, very frequently accompanies acute inflam- 
mation of the méninges : thèse phenomena show themselves almost always in the 
first stage of the disease, and often mark its commencement. Sometimes they, not 
being oftentimes repeated, attract but little attention ; and after about twenty-four 
or thirty hours, they do not return. Sometimes, on the contrary, they continue 
for several days, and occasionally during the entire course of the disease. 

Simultaneously with this vomiting, it often happens that no other symptom is 
observed connected with the digestive passages ; the tongue remains natural ; the 
epigastrium is free from pain j the entire abdomen is perfectly soft ; and, in cases 
where death has supervened, whilst this vomiting still existed, the stornach was 
frequently found in the soundest state. A striking example of a modification of 
function, which is explained to us by no change in the texture of the organ. 

If we now inquire whether the frequency of the nausea and vomiting is dépendent 
on the seat of the meningitis, we shall find that thèse symptoms are observed in 
nearly an equal proportion, whether it be meningitis of the convexity, or that of 
the base, or that of the ventricles. Thus the seat of the disease has no influence on 
the production of the nausea and vomiting. The same may be said of the nature 
of the lésion. Why, then, in two cases where the apparent lésions are the same, 
does vomiting take place in one, and not in the other ? Anatomy cannot inform 
us. Thus, every time that we wish to ascend to the cause of the inconstancy of 
the symptoms of meningitis, we cannot account for this inconstancy by the différ- 
ence of the lésions of the méninges ; and we are obliged to admit that, in the brain 
itself, there are some functional modifications, the secret of which has not yet 
been found out by the skill of the anatomist. Vomiting, when it présents the 
characters now mentioned, when, for example, a natural state of the tongue 
coincides with it, is a valuable sign to distinguish, at the commencement, the 
nervous symptoms which dépend on idiopathic irritation of the encephalon from 
those which are connected with inflammation of the intestinal follicles. We shall 
see, in the fourth part of this work, how rare vomiting is in the latter case. Such 
are the principal functional disturbances which are observed in référence to the 
stornach in cases of meningitis. With respect to the intestines, properly so called, 
they présent but very few disturbances. Thus, in ail the cases of meningitis 
exempt from complication, which have fallen under our own observation, or have 
been mentioned by others, we have found the abdomen soft and free from pain in 
ail its parts ; the stools are few; meteorism takes place only when the intestine 
itself is afFected ; and this uniform absence of meteorism is again one of the 
characters by the help of which we shall be able to distinguish a meningitis from 
a severe attack of fever ; after which we find, in the post mortem examination, no 
other lésion except in the digestive tube. 



ARTICLE IL 

Lésions of the Circulation. 

The disturbances produced by affections of the méninges in the circulatory 
apparatus may be manifested, first, in the motions of the heart ; secondly, in the 
manner in which the arterial expansions are performed ; thirdly, in the capiilary 
circulation ; fourthly, in the qualities of the blood itself. 

The heart, examined during life, presented to us no other modifications except 
those announced by the puise. After death it presented nothing particular, with 
the exception of one individual, who died with symptoms of apoplexy, and in 



62 



CLINIQUE MÉDICALE. 



whom the ventricles were found dilated by a great quantity of sérum. This 
person had an organic affection of the heart. 

The arterial expansions presented modifications to us with respect to their 
frequency, their strength, and their rhythm. From a very considérable number 
of cases of meningitis, in which the state of the puise, with respect to frequency, 
was carefully noted, we feel warranted in asserting, that nothing is more variable 
than the state of the puise in cases of meningitis. 

If, in a considérable number of patients, it be perceptibly accelerated, in others 
the arterial pulsations are not more fréquent than in the natural state ; whilst in 
others, again, they become slower than ordinary. We may note, also, that the 
proportion of the cases in which the puise remains free from frequency, or 
becomes slower, is more considérable in acute affections of the méninges than in 
the equally acute affections of the thoracic and abdominal viscera. Slowness of 
the puise becomes again a sign of considérable importance in aiding us to 
distingursh a real affection of the méninges from other morbid states which may 
resemble it. We may here refer to some cases in wiiich the méninges, coming to 
be affected during the course of another affection, the commencement of this 
complication was marked by an extraordinary change in the puise, which having 
till then been very much accelerated, suddenly lost its frequency. From the 
analysis of several cases, we have arrived at the conclusion, that the absence of 
frequency in the puise, no more than its slowness, dépends neither on the seat 
nor nature of the meningeal inflammation ; yet our expérience induces us to think 
that this state of the circulation is more fréquent when the ventricles are distended 
by a considérable quantity of liquid ; but we have also seen it in cases where the 
ventricles were perfectly sound. From the considération of several cases, we may 
venture to state, that the cases of meningitis, in which the puise was accelerated, 
seem to be more particularly cases of inflammation of the méninges of the 
convexity ; and it was almost exclusively when we found on the dead body 
lésions characterising the inflammatory state that this accélération w r as observed. 
The puise, considered with respect to its strength, présents no constant character ; 
it some cases it is hard, full, and vibrating ; whilst in others it is small and 
concentrated from the commencement of the affection. It generally becomes 
weaker and more compressible during the period of coma. Irregularity in the 
rythm of the puise has been observed in some meningeal inflammations ; but 
pathalogical anatomy is as unable to account for such a phenomenon as for its 
strength or weakness, frequency or slowness. The capillary circulation under- 
goes certain modifications in persons labouring under meningitis. Thèse are 
recognisable principally in the conjunctiva and face ; the commencement of the 
disease is frequently accompanied by great redness of both thèse parts. This 
state is sometimes succeeded by great paleness ; sometimes this paleness exists 
from the commencement of the attack, and it continues to the very last moment 
of life ; and this is observed not only in those cases where a copious effusion of 
sérum is found after death, but also in cases where dissection detected proofs of 
very active inflammation in the membranes of the brain, such as infiltration of the 
pia mater with pus, floceulent sérum in the ventricles, false membranes at the 
base of the brain. The température of the skin varies considerably in the différ- 
ent forms of meningeal affections ; oftentimes it is increased ; frequently, also, it 
remains perfectly natural in ail the phases of the disease. It is not uniformly 
raised even in those very cases where, after death, pus is found around the brain. 



DISEASES OF THE ENCEPHALON. 



63 



ARTICLE III. 

Lésions of the Respiration *. 

This function does not always remain in its natural state in persons labouring 
under meningeal affections. The disturbances which it undergoes appear to 
dépend on the influence which the affection of the nervous centres exercises over 
it. ; since, after death, we do not detect in the lungs any lésion which can account 
for the modifications observed in the respiration during life. We know from 
expérience, however, that the cases in which the respiration remained in the 
natural state are much more numerous than those in which it was in any way 
modifîed. There are, however, very few cases in which the respiration did not 
become embarrassed and stertorous during the few hours immediately preceding 
death. In some, to be sure, we see life suddenly terminate without any difficulty 
whatever in the respiration. Those cases in which the respiration continued 
natural, presented ail the possible varieties of lésion of the méninges, whether with 
respect to their nature, or to their seat. With référence to the cases in which the 
respiration was modifîed, nothing particular was observable in the morbid changes 
in the méninges ; so that here again the anatomical data are completely insuffi- 
cient to explain the variable influence which the irritated or compressed brain 
exercises over the action of the respiratory apparatus. Some cases to be pre- 
sented in a subséquent volume of this work, prove that, without any appréciable 
lésion of the brain or its membranes, the respiration may exhibit ail possible 
modifications ; for this it is only necessary that any cause whatever should disturb 
the innervation either temporarily or permanently. 



SUPPLEMENT, 

Spinal Meningitis, or Inflammation of the Membranes of the Spinal Marrowf. 

Inflammation of the membranes of the cord is seldom found limited to the extent of the 
spinal canal ; most frequently the membranes of the brain are found at the same time inflamed. 
This inflammation is characterised on the dead body by a yellowish, opaque, membraniform 

* With respect to the modifications which the several functions, &c, undergo in meningeal 
inflammation, and in order to assign the real cause on which such modifications dépend, the 
following passage is here annexed from the Cyclopaedia of Practical Medicine, vol. i. article 
" Brain :" — " The brain confessedly présides over ail the phenomena which are attended with 
consciousness, and over every act which is influenced by the will : it is th'e organ of intellect, 
and the centre of sensation and of voluntary motion. Moreover, through the pneumo-gastric 
nerve it influences directly the functions of digestion and respiration, and indirectly (through 
the respiratory apparatus) that of the circulation. Experiment also demonstrates its intimate 
connexion with the régulation of animal température. Now if we note the symptoms attri- 
buted to inflammation of the arachnoid membrane, or look over the catalogue of them as 
enumerated by différent writers, we shall find that they are but so many lésions or disturb- 
ances of one or more of the cérébral functions ; and as such they must arise from an affection 
of the organ itself, which holds thèse functions in dependence, and not of the investing mem- 
branes, which cannot exert on thèse functions any direct controul. Thus when, iu the summary 
of the symptoms of arachnitis, we find delirium, spasm, and rigidity of the muscles, convulsions, 
vomiting, stupor, coma, contraction or dilatation of the pupils, with strabismus, we must refer 
them to an altération in the function or structure of some part of the cerebro- spinal mass, and 
not of its investments merely. The arachnoid and pia mater are so simple in their structure 
and function, that we can scarcely assign to inflammatory action, when set up in them, any 
other indication except pain or headach." 

f The above Supplément has been compiled from the last édition of Ollivier's Work on 
Diseases of the Spinal Cord ; such addition was considered necessary to render the pathology 
of the cerebro-spinal System complète in this first part. % 



64 



CLINIQUE MÉDICALE. 



exudation, varring in thickness and ronsistence, sonietirnes continued the whole length of the 
cord, sometimes forming detaehed and separate patches. This exudation is usually situated be- 
tween the arachnoid and pia mater of the cord : so that, on cutting into the dura mater, the spinal 
cord appears at first sight increased in volume, and changed into a yellowish substance : such is 
uniformly the seat of this pmiform laver, which is always thicker in the posterior than in the 
anterior part of the cord. When this concrète substance is removed, \re perceive that there 
exists at the same time thickening and injection of the sub-arachnoid cellular tissue, which is 
evidently inflamed, whilst the arachnoid itself présents neither injection nor opacity. There is 
also usually in the lumbar portion of the spinal canal a sero-purulent liquid, more or less 
turbid, and in rather considérable quantity. 

Ail thèse détails are the more particularly insisted on, inasmuch as it is generally said 
that the arachnoid is then inflamed and its cavity filled with purulent matter. This assertion 
is false, and arises from want of due attention in making the examination. The purulent 
exudation is always subjacent to the arachnoid, which ordinarily retains its sniooth and 
polished appearance ; and when the cavity of this serous membrane is covered with similar 
concrétions, a thing which rarely happens, there is always at the same time a purulent exuda- 
tion between the pia mater of the cord, and the corresponding arachnoid reflexion, that is, in 
the space filled in the normal state by the spinal liquid. The ventricular parietes of the 
encephalon are also frequently found covered by a similar pseudo-membranous laver. 

Acute spinal meningitis does not always leave the same traces in individuals who die in 
conséquence of it. Sometimes it gives iïse to acute dropsy * ; the membranes have a red, violet 
tint, evidently caused by the injection of the sub-arachnoid vessels, and the serous reflexion i9 
rendered opaque by the thickening of the cellular tissue to which it is immediately contiguous. 

At other times isolated points are seen more or less injected and red, which aie évident 
traces of local inflammation ; they are seen particularly when there is caries of one or more 
vertebrae, opposite the altered part of the spine. Thèse circumscribed inflammations are 
seldom observed when there is no altération of the bones. Sometimes the cavity of the mem- 
branes is filled with fluid blood, the product of an accidentai exhalation. We have not always 
met, in persons who have died after spinal meningitis, the traces of this inflammation within the 
membranous envelopes of the cord. Bergamaschi -f- cites an instance where there was only 
found a serous effusion between the bony tube of the spine and the dura mater ; he mentions 
another instance, as does also Lallemand where a considérable effusion of blood was seen in 
this part. 

The vessels of the coverings of the cord are, in gênerai, more or less injected, but particu- 
larly those of the spine and of the pia mater. Sometimes the substance of this organ is softer 
than in the natural state ; sometimes it présents no appréciable change ; sometimes it is 
unusually hard (Bergamaschi) ; at other times it is evidently softened. In a word, inflamma- 
tion of the membranes may exist with or without inflammation of the substance of the spinal 
marrow. 

Hitherto anatoniical research lias not been able to discover any vessels in the arachnoid, and 
yet ail authors speak of its inflammation ; but it is évident that the vessels which are subjacent 
to this membrane have been considered as belonging to it. The red tint and thickening which 
it then présents, are owing, as I have already said, to the injection of thèse same vessels, and to 
the infiltration or thickening of the sub-serous cellular tissue. 

The arachnoid, says Beclard §, bas the same structure as the other serous membranes, but 
it has a very soft consistence : it is extremely thin, and its texture cannot be determined ; it 
appears homogeneous, we observe no vessels in it, even when in a state of disease. Most of the 
morbid phenomena attributed to it take place in the tissue lying on the pia mater : it seems, 
in fact, to form a separate genus altogether. Such is the cause of the opaque and whitish 
appearance which the cérébral arachnoid often présents in a part of its extent. If this mem- 
brane be examined with attention in thèse différent points, it will soon be ascertained that its 
greater density, owing probably to a chronic inflammation, is produced by the thickening of the 
cellular tissue uniting it to the pia mater, to which it is then sometimes found closely adhering. 
The inflammation which détermines thèse changes in the cérébral arachnoid has been most 
frequently of a chronic nature ; a thing which is seldom observed in spinal meningitis, the 
progress of which is usually rapid, whence it is that such opacities are not often observed in the 
vertébral arachnoid, 

The most ordinary effects of chronic spinal meningitis are adhésions between the serous 
reflexion lining the dura mater, and that corresponding to the pia mater of the spinal marrow. 
This has been frequently observed, particularly in inflammation of thèse membranes conséquent 
to a lésion of the vertebrae. Another altération of the spinal arachnoid, and one which is 

* J. Frank, Prax. Med., etc., de Rachialgite, p. 80. 
f Giornale délia Soc. Med. Chir. di Parnia, giugno, 1810. 
J Deuxième Lettre sur L'Encéphale, Obs. No. 30, p, 305. 
§ Anal. Gén. 



DISEASES OF THE ENCEPHALON. 



65 



pecûliar to it, coiisists in tlie présence of cartilaginous plates, marked with roughnesses on the 
side of the araclmoid cavity; the primary cause of their formation is not at présent easily 
determined ; they are found, however, pi'etty often in persons who have presented during life 
phenomena resulting from a chronic irritation of the cerebro-spinal centre. 

Partial injections of the spinal araclmoid have been several times observed, which appeared 
to he seated in the araclmoid itself ; but more attentive examination showed that the injected 
vessels lay heneath the serous membrane. Thèse partial injections sometimes form small red 
pointed patches, which seem to be in the substance of the serous réflexion, which then présents 
a real thiekening, and which is then often united to the fold lining the dura mater by more or 
less cellular filaments. M. Ribes (Dict. des Se. Méd., art. Vertébré) also thinks that the seat 
of the inflammation is not in the spinal araclmoid, but in the dura mater, which receives a great 
number of vessels, in the pia mater, which also contains several, and in the vessels which, from 
this membrane, penetrate into the substance of the spinal marrow. Those cases wherein a 
great quantity of blood or sérum bas been found betvveen the bony tube of the spine and the 
dura mater, support this opinion. Be that as it may, the least equivocal traces of spinal men- 
ingitis consist in a puriform exudation situate between the pia mater and the arachnoid. 

SYMPTOMS OF SPINAL MENINGITIS. 

Spinal Meningitis is often obscure at the commencement, and like many other diseases, 
announces itself only by a feeling of uneasiness and fatigue in the limbs ; there exists, how- 
ever, at the same tinie constipation, dysuria, or even a rétention of urine. The patients then 
complain of a slight pain in the back, often in the lumbar région only, which pain is at first 
dull, and which extends to the lower extremities. The existence of phenomena dépendent on 
a cérébral affection often increases the difficulty of the diagnosis at the commencement of the 
complaint : we have, in fact, seen that inflammation of the membranous envelopes of the spinal 
marrow is seldom limited to the spinal canal; most frequently those of the brain are also 
inflamed in a variable extent ; symptoms of cérébral meningitis présent themselves in many 
cases together with those of spinal meningitis. But on separating the former from the latter, 
and on bringïng together the examples of this inflammation, we find that there are two symp- 
toms which might be considered as pathognomonic signs of acute inflammation of the mem- 
branes of the cord, since they are, if not always, at least most frequently combined. 

The first consists in a gênerai contraction of the muscles of the posterior part of the trunk, 
which may vary from simple muscular rigidity to the most violent contraction, which then 
produces rétroversion of the head and trunk, whence arises a real opisthotonos, and the spine 
forms a species of inflexible arch down its entire length. We have seen this curve to exist in 
cases where the autopsy proved that the inflammation was limited to the spinal méninges alone, 
those of the brain being altogether exempt from inflammation ; so that we may consider this 
symptom as positively indicating the inflammation of the membranes of the cord. However, it 
must not be forgotten that in meningitis at the base of the brain, the cervical part of the spine 
is sometimes curved backwards ; but the rest of the trunk retains its natural straightness and 
flexibility. 

We see that this tétanie contraction manifests itself principally when we wish to make the 
patients move, and it even happens that it does not exist when the body is in a state of com- 
plète rest. The muscular rigidity is seated principally in the trunk, without the extremities 
participating in it ; thèse, however, are often equally affected. The movements, which are in 
some measure restrained by the pain, have less force, but they are not paralysed, unïess there 
be some altération of the brain which produces this effect. 

The second symptom is a pain, more or less acute, in the dorsal région ; it seems to commence 
in gênerai from the point where the inflammation is most intense, and there also it is always most 
acute. It, as well as the muscular rigidity, présents remissions, and sometimes even it disap- 
pears in order to manifest itself anew. It is marked also by irregular intermissions. The pain 
may exist without any perceptible muscular contraction ; but it is ordinarily accompanied by 
this phenomenon, or by convulsive motions, and uniformly the rigidity of the muscles mani- 
fests itself immediately, or a little time after the pain has appeared. According to some 

authors, this pain is increascd by pressure. I have not, however, observed it 

The violent pain complained of by patients along the spine is a constant symptom of spinal men- 
ingitis : sometimes it darts rapidly from the point primarily painful to the entire extent of the 
back ; its radiations are extended to the limbs, and the slightest pressure, or a mere displace- 
ment, makes the patient scream aloud. This morbid exaltation of the gênerai sensibility is 
an almost constant phenomenon in spinal meningitis, and there is commonly observed no 
diminution of this property, a circumstance which assists in distinguishing this inflammation 
from myelitis, which is ordinarily accompanied with a more or less complète abolition of the 
sensibility. Thus this sign may serve to characterise inflammation limited to the membranes 
of the spinal cord, silice in the one the sensibility is exalted, and in the other it is weakened 
or destroyed. 

F 



66 



CLINIQUE MÉDICALE. 



The conibination of the two syinptoms just desciïbed characterise in a mfmner acute inflam- 
mation of the spinal méninges, for in ail the cases in which both were observed, the autopsy 
showed an inflammation of the entire extent, or of the greater part of thèse membranes, and 
sometimes, but rarely, the inflammation occupied but a very limited space. To thèse pheno- 
mena we must add more or less acute pains in the limbs, greater or less rigidity of thèse same 
parts, trismus, and sometimes convulsions. Respiration is difficult and panting : this latter 
symptom is rather fréquent, and is readily accounted for from the nature and seat of the 
disease. The puise, which at first undergoes but little change, always préserves its regularity, 
then becomes more and more fréquent, and loses somewhat of its strength ; it is small, con- 
centrated, whilst the movements of the heart are strong and rapid. Ordinarily copious sweat 
covers the patient dnring the attack, when the tétanie contractions are intermittent. With 
respect to the paralysis and the convulsions, they may likewise dépend on inflammation of the 
cérébral membranes, which sô often exists at the same rime, or on that of the brain, and then 
the face may be red, the eyes bright and animated, thirst intense, déglutition difficult, delirium 
more or less violent, &c. Tetanus has been considered as the resuit of inflammation of the 
spinal membranes, because it has been observed several times in persons who have died of this 
disease ; but as it has happened just as often that no trace of inflammation was detected in this 
case, nothing can be inferred on that subject. Some physicians think that this inflammation 
exists principally in traumatic tetanus. However, if this inflammation is not the altération 
which constitutes tetanus, it is nevertheless tnie that it is occasionally observed, and such 
coïncidence should always be remarked. 

With the exception of the rétention of urine, and of the constipation which always exist in 
spinal meningitis, no very particular disturbance is observed in the fanerions of the other organs 
of the abdomen, nor in those of the thorax, and yet we have seen that there are most frequemly 
traces of inflammation more or less intense in the respiratory and digestive apparatus. I shall 
observe, that the abolition of the functions of the bladder always continues in the same degree 
from the commencement to the end, whilst the same thing does not happen with respect to the 
intestine, the fseces being passed naturally at the close of the disease. The movements of the 
heart appeared to be perceptibly influenced but on one occasion ; but the puise has always 
increased in frequency, and diminished in strength. As for the respiration, it is uniformly 
difficult and incomplète. 

With respect to the causes under the influence of which spinal arachnitis may develop itself 
spontaneously, it is often very difficult to détermine them. Persons subject to rheumatic affec- 
tions appear to be more exposed to this inflammation. It may also be brought on, accoi'ding 
to Vogel, by the suppression of the menstrual or hemorrhoidal flux. It is often consécutive 
on cérébral meningitis. Violent contusions, pricking or lacération of the 6pinal envelopes, 
changes produced in the vertébrée, may also bring on this inflammation, as likewise violent 
exertions of any kind. With regard to the treatment, recourse must be at once had to copious 
gênerai bleeding, particularly in the young and vigorous ; to this, which is to be repeated as 
occasion may demand, must be joined local bleeding, by means of leeches, or cupping, along 
the entire of the vertébral column. The cold affusion, and the application of ice, which are so 
advantageous in cérébral meningitis, must be equally so in an inflammation seated in a similar 
part. When the inflammation is chronic, rubefacients and blisters have been found service- 
able. The same may be said of the cautery, and of moxas. With this should be combined 
emollient and gently laxative drinks ; — laxative lavements may also act advantageously, as 
derivatives. Distension of the urinary bladder should be prevented, by sounding the patient 
frequently in the course of the day. 

Ollivier, Traité de la Moelle Epinière, vol. ii. chap. 7, &c. 



SECOND BOOK, 

DISEASES OF THE BRAIN. 



FIRST ORDER. 

CEREBRAL CONGESTIONS. 

A great number of morbid states, differing very much from each other with 
respect to the functional disturbances accompanying them, have been referred to 
congestions or hyperemias of the brain ; which states sometimes give rise to ail 
the symptoms characterising a severe attack of apoplexy, and are capable even of 
producing death more promptly than real cérébral hensorrhage, whilst sometimes 
they simulate acute inflammation of the méninges, &c. The cases now about to 
be given, are instances of thèse varied forms of cérébral hyperemia ; they will 
also show how différent are the symptoms which may be determined by one and 
the same lésion, whether in regard to the différences which it présents in its 
intensity, in its progress, in the greater or less rapidity of its production, or with 
regard even to the différence of disposition in the individuals affected by il. 



SECTION I. 

CASES. 

Case 1. — Disease of the heart of long standing — Sudden loss of consciousness and 
motion — Speedy death — Remarkable injection of the substance of the cérébral 
hémisphères. 

A woman, fifty-three years of âge, entered the hospital Cochin, in the month of 
March, 1829, presenting the following state : — Face flushed ; lips purple ; œdema 
of the lower extremities ; ascites ; speech uttered with panting ; orthopnœa ; 
pulsations of the heart tumultuous, repelling the ear, perceptible in almost ail the 
parts of the chest, except on the right posteriorly ; puise sunk, contrasting by the 
smallness of its beats with the strength of those of the heart, regular m other 
respects, and not fréquent. Cough of long standing, dry sonorous râle in différent 
points of the chest ; digestive functions duly performed ; no perceptible disturb- 
ance as far as regards the nervous centres. This woman was considered as 
affected with hypertrophy of the parietes of the heart, with dilatation of its 
cavities ; she was bled, and subjected to the use of digitalis. 

Under this treatment, aided by suitable regimen and rest, the dyspnosa and 
ascites had diminished a little, when one day, on getting up out of bed, she com- 
plained of seeing everything turn round her ; she scarcely uttered thèse words, 
when she uttered a loud scream, put her hand towards her head, and fell down 
deprived of consciousness, which she did not recover during the remainder of the 
day, and died that night. 

Post mortem. Cranium. — The arachnoid of the convexity remarkably dry. 
The grey substance of the cireumvolutions has a well marked rose-coloured tint. 
The medullary substance, which forms in a great measure the nervous mass 
situated over the ventricles, is traversed by a very great number of red points, 
each of which constitutes the orifice of a vessel gorged with blood. The ven- 

f 2 



68 



CLINIQUE MÉDICALE. 



tricles contain very little sérum ; the optic thalami and corpora striata less injeeted 
than the rest of the hémisphères. The sinuses of the dura mater were gorged 
with liquid black blood. 

Thorax. — The lungs were infarcted with an enormous quantify of frothy sérum, 
which flows out in great quantity at every incision made in their parenchyma. 
Heart very large ; its parietes thickened, and its cavities dilated. Its différent 
orifices free ; at the base of one of the aortic valves are some siight ossifications, 
which présent no obstruction to the freedom of its action. The aorta presented 
no other lésion than some cartilaginous and bony patches incrusting its parietes. 

Abdomen. — Slate-coloured . tint and enlargement of the papillae of the gastric 
mucous membrane over a great part of its extent ; liver gorged with blood ; 
spleen small and dense. 

Remarks. — Here was a case in which, before the post mortem, one might have 
supposed great cérébral hemorrhage had taken place, the patient having presented 
the symptoms characterising a violent attack of apoplexy. The scream she 
uttered, lier putting her hand towards her head before falling, indicated that she 
experienced a painful sensation in the brain. Such a cry does not usually précède 
an attack of apoplexy, it being rather connected with epileptic fits. After once 
falling without consciousness, she remained deprived of sensation and motion, and 
at the end of some hours she died in the way that apoplectics generally do ; yet 
ail that was found in the brain, was a greater than ordinary injection of the two 
hémisphères. This certainly is a very slight lésion to account for such violent 
symptoms. It is probable that a similar injection takes place momentarily in 
persons who are momentarily seized with giddiness and other signs of cérébral 
congestion, without any thing fatal resulting from it. This same injection is also, 
no doubt, the only lésion in the brain in those cases where ail the symptoms of 
an attack of apoplexy corne on, which, after continuing some hours, entirely dis- 
appear, without leaving any trace of their existence. It is not probable that in 
such circumstances hemorrhage takes place ; for the blood once effused into the 
cérébral pulp could not be so soon absorbed. We have seen cases of this kind 
in which complète hemiplegia, preceded and accompanied by loss of conscious- 
ness, and by stertorous respiration, likewise disappeared after the lapse of some 
hours. In those cases where loss of motion and sensation, Limited to one side of 
the body, seems to indicate a more deep-seated lésion in the cérébral hémisphère 
of the opposite side, is it still possible that there may be but mere cérébral 
hyperemia without any escape of blood from its yessels ? The following will 
prove that such may be the case. 

Case 2. — Attaclc of apoplexy supervening on a chronic affection of the thoracic and 
abdominal organs — Hemiplegia — Death two day-s after this attack — Considérable 
injection of the substance of the cérébral hémisphères — Nb other lésion in the 
nervous centres. 

A man, seventy-two years old, entered the Maison Royale de Santé, the 7th 
July, 1830. Six months before he had been operated on for hydrocele. When 
eighteen years old he had a copious hemoptysis ; more than three glasses full of 
blood had been expectorated by him in the space of fifteen hours. Since then 
no return of the hemoptysis, but ail his life he was subject to a cough. When we 
saw him, we discovered, on examining the abdomen, a considérable tumour, which 
could be traced into the right hypochondrium, the flank of the same side, to the 
epigastrium, to the level of the umbilicus, and even into the left hypochondrium : 
this tumour appeared to us to appertain to the liver ; it could be pressed without 
causing pain. For the last two months only the appetite was lost ; the patient 
had neither thirst, nausea, nor vomiting ; the stooîs were for a long time fréquent 
and of little consistence ; the tongue was covered with a thick, somewhat viscid 
white mucus ; there was an évident fluctuation in the abdomen ; the legs were 



DISEASES OF THE BRÀIN. 



69 



œdematous, and the bursae seemed infiltrated with a considérable quantity of 
sérum. A very loud respiratory murmur, without any râle, extending over the 
entire chest ; puise was fréquent ; skin hot ; a copious déposition of rosacic acid 
appeared in the urine. During the two following days the tongue became red 
and dry. On the lOth, at about three o'clock in the afternoon, new symptoms 
suddenly supervene : the patient loses consciousness ail at once ; and at our visit 
on the next morning, we were told that the preceding night he had had an attack 
of apoplexy. His state then was as folio ws : — He lies on his back ; face much 
injected ; eyes closed ; on raising the eye~lid, we observe the globe of the eye 
move slowly ; on bringing the finger near it, he quickly depresses the eye-brows ; 
the pupils moderately dilated, and equally so on both sides ; the right commissure 
of the lips slightly drawn upwards ; the left upper extremity, on being raised, falls 
again by its own weight as an inert mass ; no pain evinced on pinching it. The 
skin of the left lower extremity equally deprived of sensibility, and it seems 
deprived of ail power of motion. On the right, however, the extremities are 
capable of performing some movements ; when the right arm is raised, it is 
retained in the air by the patient, and does not fall again instantly as the left. 
Intelligence entirely gone ; the patient resembles a person in a profound sleep ; 
we cannot see his tongue. The puise lost the frequency it had the preceding 
days. (Bleeding to sixteen ounces — blisters to the legs — purgative lavement.) 
During the day, the patient gave some signs of consciousness, and spoke a little. 
On the following morning there was a visible improvement — he answered 
questions with précision — lips and tongue in the natural state — he was also able 
to perform some motion with the extremities of the left side ; but thèse limbs 
were evidently weaker than those of the right side ; their sensibility was also 
less ; puise had resumed some frequency. Towards noon ail consciousness was 
again lost ; face very much injected, and up to the following morning he remained 
in a state of coma, from which nothing could arouse him. At our visit at eight 
o'clock, we find him absolutely in the same state as on the preceding evening ; 
respiration stertorous ; he died at noon. 
Post mortem, nineteen hours after death. 

Cranium. — The méninges very much injected; sinuses of the dura mater full of 
blood. Through the entire extent of the cérébral hémisphères, every slice of the 
nervous puip presented a very remarkable number of red points. In some places 
thèse red points, which are the orifices of so many vessels with blood, are so 
densely collected, that there resuit from them bright red spots, a franc pièce in 
diameter. 

Thorax. — Close adhésions of the left pleura above and behind ; the bronchi 
considerably dilated ; at the summit of the left lung, there is a black colour, as 
also an induration of several lobules. In the midst of thèse lobules, which were 
become imperméable to air, were found several small bony concrétions, ail nearly 
the size of a grain of barley. Thèse concrétions are as hard as real bone : several 
of them were ramified. Beside them were found other concrétions of softer con- 
sistence, like lime on which a little water was thrown. Close adhésions of the 
pleura towards the summit of the right lung ; in this summit were discovered 
cavities communicating with one another, which might at first be taken for 
caverns, but which a closer examination showed to be bronchi very much dilated. 
Around them were several lobules, black and hard ; liquid black blood filled the 
right cavities of the heart ; the left ventricle empty ; a black clot, of some con- 
sistent, distended the left auricle ; a little ossification at the base of the aortic 
valves. Some small bony patches scattered over the aorta. 

Abdomen. — Limpid sérum in the peritoneum ; on the inner surface of the 
stomach, towards its small curve, was an ulcer about the breadth of a five franc 
pièce, at least, with everted edges. The tissue constituting its bottom and edges 



70 



CLINIQUE MÉDICALE. 



possessed ail the characters of encephaioid matter. The liver very voluminous ; 
about two-thirds of it were changed into encephaioid substance : we observed, 
there also, first agréât development of the circumvolutions of the yellow substance ; 
in several points, a bright red colour seeming to dépend on an unnatural develop- 
ment of the vascular tissue : secondly, in other parts was found mixed with the 
tissue of the liver a pale greenish substance, possessing ail the characters of fibrine 
which had lost a considérable part of its colouring matter, such as is often found 
in the cavities of the heart : thirdly, on removing still more of its colouring matter, 
this substance appeared changed into encephaioid matter ; spleen very dense 
and hard. Between the spleen and kidney was found an encephaioid mass of 
the size of a pullet's egg ; two other smaller masses, the size of a nut, were 
attached to the great epiploon. 

Remarks. — This case resembles the preceding in the rapid manner in which 
the symptoms came on, as well as in the nature of the latter ; here again is a group 
of symptoms similar in every respect to those characterising an attack of 
apoplexy ; and on opening the body we find not a trace of hemorrhage in the 
brain, but only a very remarkable injection of its vessels. This injection, which 
gave an almost uniform red tint to some parts of the brain, was equal in both 
hémisphères ; and yet motion was abolished in only one side of the body, 
precisely as in cases where one of the hémisphères has become the seat of effusion 
of blood. Another instance of the inadequacy of our présent means of inves- 
tigation to explain the infinité variety of the symptoms by anatomical lésions. 
And, observe, we cannot here even call the play of sympathies to our aid; 
for certainly the hemiplegia did not dépend on them. The latter symptom 
disappeared twenty-four hours after it occurred. then it returned, and this cir- 
cumstance might hâve inclined one to think that the cause which produced it, 
was not itself connected with any serious lésion of the brain : the intelligence also 
returned for a time ; but that is also observed in cases of cérébral hemorrhage. 
The hemoptysis, which appeared in early life, and never returned, as also the 
bony concrétions in one of the lungs, the dilatation of the bronchi of the other 
lung, and the morbid structures seated in several of the abdominal viscera, reuder 
this a very remarkable case. 

Case 3. — Signs of cérébral congestion existing for several years— On a sudden 
hemiplegia of the right side not preceded by loss of consciousness, subsequently 
sudden abolition of intelligence, coma, and death. 

A woman about fifty years of âge entered the Hôpital Cochin with an ascites 
of several months' standing. She stated that for ten years she had scarcely passed 
a week without being affected with dizziness so great as to oblige her to seek 
support to prevent her from falling. Thèse dizzinesses used to last for some 
minutes ; they were accompanied with tinnitus aurium, and often when they 
ceased, the patient used to feel a pricking sensation at the ends of the fingers, 
which were occasionally as if numbed. There are some days, she says, when the 
objects which I touch are séparât ed from my hand by a pièce of velvet. However, she 
never lost consciousness ; intellect clear and memory good. She expressed a 
great wish to be tapped, and I yielded to her request. After the fluid was 
removed, I discovered in the right hypochondrium a large tumour which extended 
to the navel, which at this part terminâtes in a blunt edge, and resembles in 
every way an enlarged liver. This tumour is found in the epigastrium ; it disap- 
pears towards the left hypochondrium. Three days after the tapping the patient 
became weak, her tongue became a little dry, when, after another attack of 
dizziness without loss of consciousness, she felt, as often before, a numbness of 
both hands, but principally of the right ; this numbness continued longer than 
usual : she fell asleep about eleven at night ; on awaking she could not move 



DISEASES OF THE BRAIN. 



71 



the extremities of the right side. The following day, complète hemiplegia of the 
right side ; the sensibility of the paralysed limbs still perfect ; intellects good. 
The two days following the hemiplegia continued. On the third day after the 
hemiplegia appeared, speech altogether suspended ; she can no longer give any 
sign of intelligence ; the four extremities when raised fall as inert masses ; eye- 
lids closed; and when we raised them, the globes of the eyes remained immove- 
able. Coma then came on, and in two hours after the respiration became stertorous, 
and she died. 

Post mortem. Cranium. — Vessels of the cérébral membranes gorged with blood ; 
remarkable rose-coloured tint of the grey substance of the circumvolutions ; 
unusual injection of the medullary substance of the cérébral hémisphères, equally 
marked on both sides. 

Tiiorax — Great infarction of the lungs ; heart sound. 

Abdomen. — Occupied by an enormous tumour, which conceals ail the other 
viscera. This was an enkysted dropsy of the right ovary ; it consisted of two 
parts ; the upper part solid, which by reason of its situation, form, and relations, 
had been looked on as a tumour of the liver ; the lower one was softer, and gave 
on pressure a manifest sensation of fluctuation. Internally it consisted of a great 
number of cells, which contained various sorts of fluid. 

JRemarks.— Here is another form of cérébral phenomena; and on examination 
the same state of the nervous centres, sanguineous congestion of them, and nothing 
more. In this case the patient had been for several years threatened with 
apoplexy ; then at the end of one of those giddinesses to which she was subject, 
she was struck with hemiplegia, and soon after died amidst the total suspension of 
the functions of the life of relation. There is this notable différence between the 
présent case and that which précèdes it ; it is, that in the one the loss of 
consciousness coincided with the hemiplegia ; whilst in the case now before us., 
the paralysis preceded the loss of consciousness. Thus ail the combinations 
of symptoms produced by cérébral hemorrhage may co-exist with a simple 
sanguineous congestion of the encephalon. In the following case we shall see 
other symptoms appear, which are no longer those of simple hemorrhage, and 
are ordinarily regarded as more particularly connected with softening of the 
brain. 

Case 4. — Pulmonary phthisis — Sudden loss of consciousness with permanent 
flexion of the left upper extremity — Death twenty-seven hours after the appear- 
ance of thèse symptoms — No other lésion in the nervous centres, except a bright 
red in jection of their substance. 

A man, thirty-six years of âge, entered the hospital La Pitié with ail the signs of 
phthisis already far advanced ; for some days he complained of a rather acute 
pain towards the right temple, and a slight numbness of the extremities of the 
left side ; then on leaving his bed one morning he fell suddenly, deprived of con- 
sciousness. When carried to bed he did not corne to himself, and the following 
morning we found him in the following state : — Face very much injected ; his 
attitude that of a person asleep; answers no questions, and appears quite a 
stranger to every thing passing around him. The left commissure of the lips 
slightly drawn up. The tongue cannot be seen ; the Angers of the left hand 
strongly flexed on the palm of the same hand, and cannot be extended. The left 
forearm is also flexed on the arm, so as to form with it a very acute angle; the 
right upper extremity when raised falls again as an inert mass, as do also the two 
lower extremities ; puise small, not fréquent ; respiration embarrassed. Two hours 
after we left the patient, the two upper extremities were agitated by convulsive 
movements which did not last, and in the afternoon he died. 

Post mortem. Cranium. — The substance of the two cérébral hémisphères was 
very much dotted with numerous red poiits. 



72 



CLINIQUE MEDICALE. 



Thorax. — Tubercular excavations in the two lungs ; heart firm, with slight 
hypertrophy of the parietes of the left ventricle : black liquid blood in its cavities. 

Abdomen. — Greyish tint on the inner surface of the stomach ; numerous tubercles 
in the small intestine ; liver and kidneys gorged with blood. 

Remarks. — The symptoms here were similar to those which so often announce 
softening of the brain, and y et there was no trace of such a lésion ; and, notwith- 
standing the différence in the phenomena on both sides of the body, a sanguineous 
congestion, equal on both sides, was ail that was discovered. Why was there 
flexion of the limbs in this case, and not in the preceding cases ? Anatomy does 
not inform us. Is it not a circumstance worthy of remark, that the four cases of 
cérébral congestion now reported regarded individuals labouring under chronic 
affections at the time the brain became congested in them ? In three of them 
hematosis was for a long time vitiated ; they were meagre, bloodless, and 
appeared to be in a condition entirely opposite to that which is usually laid down 
as favouring cérébral congestions. An additional exampie to prove that the facility 
with which local hj^peremias are produced, is not always in the direct ratio of 
the plethoric state of the subject. The following will confirm this assertion still 
more, since it will be in another phthisical patient, that we shall see cérébral 
congestion to supervene, but with quite other symptoms. 

Case 5. — Fébrile delirium followed by coma, which came on during the 2>rogress of 
a pulmonary phthisis — Tlie cérébral hémisphères marked with bright red points. 

A boy, eighteen years of âge, entered the Maison de Santé, 16th July, 1830, 
in a complète state of delirium. We ascertained, from those who brought him, 
that having been ill a long time, and having had several times abundant hemoptysis, 
lie had been seized, without any known cause, on the night of the 14th Julv, with 
a violent headach, which was taken to be a mere niegrim. This pain of head 
continued ail the night, and the following morning it was complicated with vertigo 
and tinnitus aurium. He was desirous to get up, but he soon lay down again in 
conséquence of the dizziness he felt when he stood up. Ail the day he continued 
to complain very much of his headach. In the evening delirium commenced. He 
was brought to the Maison de Santé on the 16th, in the morning, when his state 
was as follows : — Face red ; eyes injected, and in continuai motion ; foam at the 
mouth ; delirium complète ; extraordinary loquacity ; constant moving of the 
limbs ; tongue whitish, moist, a litlle red at the apex ; abdomen soft ; stools 
passed involuntarily ; puise very fréquent ; skin hot and moist (bleeding to sixteen 
ounces ; mustard cataplasms to the legs). During the night he uttered loud cries. 
On the 17th the delirium still continued. He was bled again to the same amount 
as before. When the blood ceased to fiow, convulsions of the limbs came on, 
which stopped after a few minutes. On the ISth, profound coma ; can neither 
see nor hear ; the four extremities in a state of complète resolution ; conjunctivse 
very red ; puise very fréquent (twenty leeches were applied to the neck). In 
the evening he suddenly émerges from coma, utters loud screams, and it became 
necessary to restrain him by force in bed. The coma returned towards midni°-ht 
On the morning of the 19th, we found the features quite altered ; prostration of 
strength greater ; puise more fréquent (sinapisms to the lower extremities). He 
died the following night. 

Post mortem. Cranium. — Vessels of the méninges very much injected ; the 
circumvolutions marked with a rose-coloured tint ; the medullary substance of the 
hémisphères very much dotted with red points ; a few drops of limpid sérum in 
the ventricles. 

Thorax— Tubercles in every stage in the two lungs ; an immense cavern in the 
summit of each of them. 

Abdomen.— An extent of the gastric mucous membrane equal to about a five 
franc pièce, near the pylorus, marked with red points ; some tubercles in the 



DÎSEASES OF THE BRAIN. 



73 



small intestine ; gênerai paleness of its mucous membranes, except about six 
inches above the caecum, where it is injected. This injection was also found in 
the caecum, and in the ascending colon, and in its sigmoid flexure. 

Remarks. — This case présents symptoms altogether différent from those which 
the four cases preceding it presented. They are similar to the symptoms of acute 
meningitis, or to those produced by certain gastro-enterites, which re-act on the 
nervous centres. Was the congestion, then, of which the traces were discovered in 
the brain, the real cause of the nervous symptoms ? If not, where is the cause ? 
Is it to be referred to the bright red injection presented by the termination of the 
ileum, and a part of the large intestine ? But how often have we not found a 
similar injection, without anything analogous in the symptoms ? If we admit that 
the entire disease may be explained by the state of the organs after death, we 
shall refer the entire matter here to the cérébral congestion, either primitive or 
consécutive to the intestinal injection, which we shall call entero-colite ; and if 
we be asked, why, of five cases, where the cérébral lésion is the same, there are 
not two resembling each other in the symptoms, we shall not be able to solve this 
objection otherwise than by admitting in each what has been conventionally styled 
idiosyncrasy. There remains another mode of interpreting the facts ; it consists 
in admitting, that this sanguineous congestion, which is produced in ail our cases 
with functional disturbances so varied, is itself but an effect, and that it is not 
given us, with our présent means of investigation, to ascertain the cause which 
produces this congestion, at the same time that it créâtes those différent groups of 
symptoms which we traced in each of the five preceding cases. 



RECAPITULATION. 

The cases which have been just now reported, have shown the principal forms 
symptomatic of hyperemia of the cérébral hémisphères. On combining with those 
few cases which ended in death, several others of the same kind which terminated 
favourably, we have been led to lay down, that cérébral congestion may présent 
itself to us in one of the eight following forms : — 

The first form is characterised principally by dizziness of greater or less inten- 
sity : the patients may be affected at the same time with pain of head, dazzling, 
tinnitus aurium, momentary aberrations of vision, temporary embavrassment in 
speech, a sensé of formication in the limbs, and sometimes at the face. The 
countenance is generally fiushed, eyes injected, puise in gênerai not fréquent, and 
of variable strength. This state may last but for some moments, or some hours ; 
but it may also be prolonged for several months, nay, continue even for several 
years. In some persons it shows itself but once ; in others it reappears at inter- 
vais more or less remote. We have seen a man fifty-nine years of âge, who, for the 
last thirty years, had not passed a single day without having in différent degrees one 
or other of the symptoms mentioned in the preceding paragraph. Another person 
had experienced them since the âge of thirty years till be was thirty-four. He 
then became completely freed from it till the âge of forty-eight, at which time he 
was again attacked with violent dizziness. We noticed the case of several 
persons in whom every year, nearly in the same month, thèse attacks of dizziness 
reappeared. In some females they manifest themselves regularly at the return of 
each menstrual period. 

After this dizziness has lasted a shorter or longer time, it may happen that they 
attain ail at once such an intensity as to be changed into a sudden loss of consci- 
ousness ; but the latter may likewise supervene without having been preceded by 
dizziness. It is this sudden loss of consciousness, with or without preceding 



n 



CLINIQUE MÉDICALE. 



dizziness 5 which characterises the second form of cérébral congestion. In this 
form the patients fall to the ground, deprived suddenly of ail intelligence, sensation 
and motion ; but if their lirnbs be raised, they do not fall back again by their own 
weight, and some patients can sustain them in me air. There is not then, properly 
speaking, any paralysis. They may reinain in this state from some minutes up to 
twenty-four or thirty hours : then they corne to themselves, and are quickly 
restored, without retaining any lésion either of sensation or motion. Others, after 
having corne to themselves. retain for some days a little difficulty in the per- 
formance of some of the fonctions of the life of relation. Thus their speech is 
embarrassed, or their différent movements are difficult. 

At the same time that the patients fall deprived of consciousness, they may be 
struck with paralysis, either gênerai, or confîned to only one side of the body. 
This is the third form of cérébral congestion. But almost at the same time that 
the loss of consciousness disappears, the paralysis is also seen to disappear, so that 
cérébral hemorrhage cannot be admitted to hâve taken place in this case. The 
cases we have cited prove the possibilité of this paralysis, without any effusion of 
blood having taken place into the brain. Insteadof gênerai or partial suspension 
of motion, this function may be performed in a manner disorderly and irregular, 
and without any participation of the will. Then at the same time that there is 
loss of consciousness, there are observed, either différent convulsive movements, 
or permanent contraction of a certain number of muscles ; ail thèse symptoms last 
at the utmost for some hours, they then disappear, without leaving any trace 
behind. This constitutes the fourth form of cérébral congestion. In a fifth form, 
there is no longer loss of consciousness ; it is paralysis that cornes on at the very 
first, sometimes limited to certain muscles of the face, sometimes extended to the 
entire of one side of the body. This paralysis disappears very promptly, often- 
times a few hours after having commenced ; and from this circumstance it is not 
to be presumed that it is connected with a hemorrhage, or softening. Our fourth 
case actually proves the contrary. The course of this paralysis was very remark- 
able in the following case» A middle aged man working in the quarries near 
Paris, was suddenly seized, on fmishing his dinner, with a numbness of the riffht 
hand; an hour after the entire upper extremity was totally deprived of motion ; 
no pain is felt in it : nor does ne complain of his head. At 5 o'clock in the 
evening, he had a sensé of formication in the right foot : soon the power of motion 
was equally lost in the lower extremity of the right side : he entered the hospitai 
Cochin. On the following morning the hemiplegia of the right side was complète ; 
the sensibility of the paralysed limbs was still retained ; he cannot move the right 
cheek, and when he speaks, the left commissure of the lips is drawn up ; the 
direction of the tongue is straight, intelligence perfect ; he feels a numbness (this 
is his ovrn expression) towards the frontal région ; he was bled to sixteen ounces. 
In the course of the day he was able to make some slight motion with the 
extremities of the right side. On the following morning there was no trace of 
paralysis. This certainly is not the way in which the effects of cérébral hemorrhage 
disappear, or of any lésion affecting the interior of the nervous mass. 

The sixth form of cérébral congestion is characterised by the sudden appearance 
of convulsive movements, partial or gênerai, without preceding loss of conscious- 
ness. Thèse movements promptly disappear, without leaving any trace behind 
them. They may also corne on, after the persons have experieneed attacks of 
giddiness for a shorter or longer time, and the latter may even survive them. In 
a seventh form, the cérébral congestion no longer produces coma ; it no longer 
exercises any perceptible influence on the movements ; the intelligence is the 
function here especially disturbed ; violent delirium is observed, accompanied with 
great development of muscular strength ; most frequently, some time before death, 
the delirium is replaced by a state of coma, which becomes more and more pro- 
found : however, we have ourselves seen cases in which, up to the moment of 



DISRASES OF THE BRAIX. 



death, the patients retained great agitation of the limbs, and ceased not to speak 
and vociferate. The most remarkable case of this kind which we met was that of 
a middle-aged man, who for several hours uttered incessantly cries so loud as to 
disturb the rest of the entire ward. Suddenly he was no longer heard ; when we 
approached bis bed he was dead. A thunderbolt could not have struçk him more 
promptly. 

On opening the body no other lésion was detected except considérable injection 
of the nervous mass. We shall now notice the eighth form of cérébral congestion, 
of which our fifth case présents us an example. In this form we see continued 
lever appear at the commencement, during which those symptoms principally 
predominate, which appertain to the first form of cérébral congestion already 
described. We particularly observed this form in some young soldiers, who were 
admitted in considérable numbers into our wards at La Pitié, in the beginning of 
the summer 1831. After laborious exercise, several of thèse soldiers were seized 
with violent pains of head, vertigo, ringing of the ears ; some even fell suddenly 
deprived of consciousness, and on coming to themselves they remained with the 
symptoms above detailed. On entering our wards, a little time after the attack of 
their malady, they presented to us the folio wing state : — Face red ; eyes injected 
and moistened with tears ; ringing of the ears, vertigo ; great dizziness, which 
prevented them from standing erect without being threatened with falling ; fré- 
quent epistaxis ; gênerai debility ; continuai tendency to sleep ; puise strong and 
fréquent ; skin hot ; no appréciable altération with respect to the digestive or 
respiratory organs. This group of symptoms lasted from between three to twelve 
days ; almost ail of them were bled ; some were merely subjected to the use of 
diluent drinks. By degrees the fever lessened, according as the symptoms of 
cérébral congestion disappeared. No doubt it was not demonstrated that ail the 
disease in thèse cases was in the brain ; perhaps there existed only mere gênerai 
over-excitement, in which this organ participated. But the prevailing symptoms 
were always those of cérébral congestion, and, on the removal of the fever, thèse 
were the only symptoms observed, and the only therapeutic indication was to 
combat them. Noue of thèse cases terminated fatally : in one patient only there 
was momentary delirium ; in others, the attacks of dizziness were for some days 
so violent, that we dreaded lest they should terminate in apoplexy. 

Let us now consider the causes, under the influence of which cérébral conges- 
tions more particularly develop themselves. We shall first see what influence 
the différent degrees of atmospheric température possess over cérébral hyperemia ; 
and first, with respect to the influence of an elevated température : this is repre- 
sented by the portion of the thermometric scale meluded between *20°c. and 
f 50° c. above Zéro. For, ac a higher température than that of 50°, man can no 
longer prolong existence beyond a few minutes. From 50° to J 40° c. man 
resists, or dies rapidly with ail the sîgns of cérébral congestion. From 40° to 
§ 35° c. the same phenomena are still observed. We have had an opportunity of 
examining the bodies of some who died under the influence of this température : 
there was found in them sometimes simple cérébral congestion, sometimes effusions 
of blood into the substance cf the brain. Among the cases of this sort which we 
might cite, we found few as interesting as the following jj : — 

Three labourers, occupied in three différent places in getting in the harvest 
during days when Reaumur's thermcmeter marked r 40 e in the sun, died sud- 
denly. The circumstances accompanying thèse three deaths could be ascer- 
tained only in two of them, for the third was found dead. According to the eye- 
witnesses, the two former could not have left their work more than five minutes 
before their death. They turned round, putting their hands forward, as if they 



* 68° Fahrenheit. f 122° Fahrn. % 104° Fahrn. § 95° Fahi-n. 

|| Bibliothèque Médicale, tome 70, p. 250. f 122° Fahrn. 



76 



CLINIQUE MEDICALE. 



had been deprived of sight, and must have expired at the moment when 
they appeared merely to wish to sit down. The individual who died first, that 
is, on the 6th of July, was a man of mature âge, but putréfaction made such 
rapid progress, that it was impossible to keep his body till the proper time for 
examining it. 

The second died on the following day. It was a woman, twenty-one years of 
âge. Her body was examined. Muscles well developed ; ail the articulations 
were corapletely rigid ; on the back and face were livid spots, and already the 
odour of putréfaction began to manifest itself ; abdomen tympanitic, smooth, and 
free from spots. On examining the cranium. the hairy scalp was found thick, and 
well furnished with hair ; the bony case, on the contrary, was extremely thin, but 
sufhcientiy furnished with dipîoë ; the dura mater was natural in every part, and 
no effusion was observed between it and the bones of the cranium, nor was any 
found over or under the pia mater, but the veins and arteries of thèse two mem- 
branes were gorged with blood. The brain presented no irregularity, onlv its 
substance was very soft : the ventricles contained a little more sérum than natural ; 
the lungs had contracted adhésions with the pleura costalis, but thèse adhésions 
were constituted only of a sort of filaments rather than membranes ; no sign of 
inflammation of the lungs or pleura, nor any effusion ; the lungs were very large, 
filled with air ; the pulmonary vessels were gorged with blood, and the bronchi 
fiiled with frothy mucus ; the pericardium adhered to the heart just as the lungs 
did to the pleura costalis, by filaments, and contained a considérable quantity of 
sérum ; size of the heart natural ; right ventricle a little distended, filled with 
liquid black blood ; the left ventricle was contracted and empty. On opening the 
abdomen, an infectious odour was diffused ; the intestines were filled with gas, 
their convolutions, lodged in the pelvis, presented some red spots ; the portion of 
intestine in the vicinity of the gall-bladder had a deep tinge of yellow ; the gall- 
bladder contained but a small quantity of natural bile ; ail the other viscera were 
sound. with the exception of the organs of génération ; the fundus of the utérus 
was intensely red ; the right ovary had contracted adhésions to the Fallopian tube 
and the peritoneum ; its vesicles were filled with black coagulated blood ; the 
cavity of the utérus contained a little liquid blood ; this was removed with a 
sponge, but mereiy compressing the parietes of the womb caused a new quantity 
to reappear through an immense number of vascular orifices ; besides, there was 
obtained, on pressing the neck and orifice of the utérus, a fatfy yellowish 
substance, every way like to the coat with which the vagina and labia majora 
were covered. The diameters of the utérine cavity were much larger than 
natural, and the utérus itself, far from being flattened, had the form of a pear. 
In the cavity of the pelvis there was found an effusion of about two ounces of 
blood. 

The third person died suddenly on the Sth July. This was a stranger, a woman 
between forty-eight and fifty years old. We proceeded the following day, in the 
morning, to examine her body. She was of the middle size, rather fat than 
otherwise. Ail the articulations were rigid ; the back was traversed by blue 
spots ; almost the entire face was covered with them ; the face, from the chin to 
the nose, was absolutely livid ; several also were to be seen on the chest, the 
size of wdiich varied from that of a lentil to that of a twenty sous pièce. Thèse 
spots had precisely the appearance of petechiae, and yielded, when eut into, some 
liquid blood. The body was still warm, but already it exhaled a fetid odour ; the 
abdomen was tympanitic ; the integuments, and bones of the cranium, presented 
nothing extraordinary ; their vessels, as well as those of the brain, contained some 
liquid blood ; the cérébral substance was extraordinarily softened ; the latéral 
ventricles contained a bloody sérum ; the cartilages of the ribs were ossified ; the 
rîght lung adhered intimately to the pleura costalis ; the left side was quite free, 
The pericardium presented a slightly inflammatorv tint on its inner surface ; the 



DISEASES OF THE BEAIN. 



rigbt ventricle of the heart contained a little black liquid blood ; the blood of 
the leit ventricle was red and frothy ; the abdominal cavity contained a pint of 
serous effusion, the odour of which was putrid ; the intestinal canal was very rauch 
distended with gases, and the parts of it near the gall-bladder had a yellow tinge ; 
the latter was empty. 

According as the température is lowered, though it should be still considered 
very much elevated, the phenomena just now mentioned become more rare ; they 
are still observed from 35° to 30° c. ; but below the latter degree, from 30° 
to 20° c. (the température of our waxm seasons), the tendency to cérébral con- 
gestions disappears ; and at the latter lirait, the frequency of the hyperemia of 
the nervous centres ceases to be in the direct ratio of the élévation of the tem- 
pérature. Far from that, observation proves that, in the cold seasons of our 
temperate Europe, the frequency of cérébral congestions increases. Thus, in 
Holland, it has been ascertained that, during a period of twenty years, winter was 
the season when thèse congestions were most numerous ; after winter, autumn 
furnished most cases ; then spring, then summer *. In a climate very différent 
from that of Holland, at Turin, an average of twenty-five years showed the range 
of the seasons to be in the following order with respect to the frequency of cérébral 
congestions : winter, spring, summer, autumn j\ 

In Paris, the statistical researches of M. Falret led him to conclude that con- 
gestions and hemorrhages of the brain are more fréquent in winter than in summer 
and spring. In 114 cases, which fell under our own observation, in which we 
noted the month of the year in which the cérébral congestion took place, the 
following is the resuit : — 

For the months of December, January, and February, 50 Cases. 
For the months of June, July, and August, . . 36 
For the months of Marcli, April, and May, . . 31 
For the months of September, October, and Xorember, 17 
Very low température, as that for example to which our army was subjected at 
the time of the retreat from Moscow, favour the development of cérébral conges- 
tions, as well as a very high température. 

M. Larrey informs us that most of the persons who died in that retreat were at 
first affected with dizziness and vertigo ; they then fell into a state of somnolence, 
which was soon succeeded by profound coma, and finally by deathj. The sudden 
transition from one extrême of température to another should also be set down 
among the number of atmospheric influences, which hâve produced cérébral con- 
gestions in more cases than one. In a word, thèse congestions find at least an 
occasional cause of development in the two extrêmes of température, and they are 
reduced to their minimum of frequency by the influence of a mild and uniform 
température. There are also times, when, ail at once, without anv known cause, 
cérébral hyperemias, with or without effusion of blood, arefound to occur in con- 
sidérable numbers. 

Baglivi, in 1694, and Lancisi, in 1705, saw apoplexy suddenly become so 
common in certain parts of Italy, that they have described it as having been in 
those years really épidémie. Among those attacked with it, some presented the 
différent signs characterising simple cérébral congestion ; the others, and those in 
gTeat number, had still more ; for after the attack they continued hémiplégie, 
which would make one suppose that they had had cérébral hemorrhage. Baglivi 
remarks that this épidémie apoplexy, which struck terror into the population, was 
preceded by unusual atmospheric circumstances : to a broilîng hot summer had 
succeeded a winter so severe, for the country about Rome, that ail the fields were 
covered with snow, and this severe winter was followed by a summer still hotter 

* Annales d'Hygiène Publique et de Médecine Légale, ii. 234. 
t Annales d'Hygiène Publique et de Médecine Légale, ii. 234. 
X Campagnes, tome iv. p. 127. 



78 



CLINIQUE MÉDICALE. 



than the preceding, during whieh, for the space of five months, there fell not one 
drop of rain ; then the folîowing winter was remarked for constant rains. 

We know nothing positive regarding the influence which the greater or less 
quantity of electricity, with which the atmosphère is charged, may exercise on the 
production of cérébral congestions. Here, however, is a fact which may be 
adduced to show, that electricity, employed as a therapeutic agent, may at least 
favour the development of thèse congestions. A mau, after having been for a 
long time subject to fréquent attacks of dizziness, induced by cérébral congestions, 
and which disappeared under the influence of blood-letting and purgation, had an 
attack of apoplexy with hemiplegia, loss of speech, grinding of the teeth ; respira- 
tion irregular, sometimes slow, and sometimes fréquent ; puise intermittent, and 
sometimes scarcely perceptible, without, however, any sign of gastro-intestinal 
irritation ; repeated blood-letting and révulsive purgatives soon restored him to a 
tolerable state. At the end of some months every brain symptom disappeared ; 
puise more regular ; the use of speech had nearly returned, as also some degree of 
motion in the affected limbs, when Dr. Strambio wished to try electro-puncture in 
order to restore innervation to the half-paralysed side. Dr. Fantonelli performed 
the opération in the folîowing manner : he introduced aneedle into the lower part 
of the neck, on the side opposite the paralysed limbs, then another needle into the 
external malleolus of the affected leg ; a metallic wire, communicating with the 
two needles, was brought in contact with a voltaic pile of five dises only, so 
that the négative pôle corresponded with the needle of the affected part : the 
introduction of the needles was not painful ; but at each stroke of the pôle, strong 
pains and violent contractions were manifested in the muscles nearest to the 
needles, and principally in those of the part affected. After five or six electric 
shocks, it became necessary to desist, the pain becoming intolérable : the electro- 
puncture was repeated three times after one day's interval. After the first 
experiment, the patient was more cheerful, and performed the several movements 
with more freedom ; at the second, he experienced some uneasiness ; and at the 
third he was attacked with 'violent fever, with ail the appearances of a cérébral 
congestion. Bleeding and révulsives soon quieted thèse symptoms ; but his 
former state returned. At présent, his speech is nearly gone, and the movements 
of his leg are very weak. Arnica and rhus radicans were tried, but to no 
purpose, nay, rather with disadvantage. More positive researches than any yet 
made, are necessary to establish, how far a diet usually strong and exciting directly 
influences the production of cérébral congestion. In order that it should do so, 
we think that there must be at least a disposition on the part of the individual. 
Alcoholic liquors will beyond ail doubt produce cérébral congestion. Nothing 
resembles some of the forms of cérébral congestion described by us more than 
intoxication. We have had twice an opportunity of opening the bodies of persons, 
who, after indulging in strong liquors to excess, fell down drunk dead * (ivres 
morts), according to an expression consecrated by use. What we found was as 
follows : In both the pia mater covering the convexity of the cérébral hémisphères 
was very much injected ; the grey substance of the circumvolutions parricipated 
in this injection ; the entire substance of the hémisphères was traversée! by a great 
number of red points ; the ventricles contained a moderate quantity of sérum, the 
cerebellum was also injected, as well as its membranes, but not more than the 
brain. In no part was the consistence of the nervous mass altered. We found 
neither in the ventricles, nor elsewhere, any odour of alcohol, as was discovered 
within thèse ventricles in an individual whose case is given in Dr. Cooke's work 
on Nervous Diseases. In this latter case, the body was opened immediately after 
death ; there was found in the ventricles a clear fluid, which had the taste and 

* The expression which use has consecrated among us, namely, dead drunk. is used io 
sigmfy not precisely the saine thing as is here rneant hy ivres morts. — Tr. 



DISEASES OF THE BRAIN. 



79 



smeïl of aîcohol, and which took fire on being brought near a burning body. In 
one of the cases we examined, the mucous membrane of the stomach presented, 
in several parts, near amounting to one third of the stomach, a surface dotted with 
bright red points ; in the other, the gastric mucous membrane was of a white 
colour ; it was not softened in either case. 

Alcoholic liquors have not only caused cérébral congestions ; they have also 
sometimes produced hemorrhage either around the brain into the sub-arachnoid 
cellular tissue, or into the nervous substance itself. Thèse facts prove beyond a 
doubt, that alcoholic liquors produce drunkenness by acting directly on the brain, 
and not through the intervention of the stomach. Here is what was observed 
regarding the symptoms in one of the abovementioned cases (the second). A 
man was brought to the La Charité about an hour after having drunk an enormous 
quantity of brandy and other alcoholic liquors. For the last half hour, he had 
been in a state of the most profound coma ; skin seemed insensible ; respiration 
stertorous ; pupils exceedingly dilated ; puise fréquent and fulh This state lasted 
without any change for twenty-four hours ; it then ceased, and was suddenly 
replaced by furious delirium ; the latter lasted about tifteen hours ; at the end of 
this time the coma returned, the respiration became more and more embarrassed, 
and the patient died. We have already seen the lésions found on the dead body. 
Active treatment was employed ; he was twice bled ; thirty leeches were applied 
to the neck ; his head was covered with ice, and his lower extremities were sur- 
rounded with sinapisms. This group of symptoms, as well as the post mortem 
examination, sufficiently prove the direct influence exercised on the brain by 
alcoholic préparations. 

A great number of substances, ranked as narcotic poisons, have commonly the 
effect of determining in the brain a greater or less congestion. But, certainly it is 
not by this congestion alone, that the spécial phenomena produced by each of them 
can be explained. Let a man have been poisoned by alcohol, by opium, bella- 
donna, tobacco, digitalis, camphor, prussic acid, &c, there will always be found in 
the brain, when examined after death, one and the same modification, which will 
vary only in intensity ; this will always be an hyperemia ; and yet, what can be 
more dissimilar than the functional disturbances to which the use of thèse sub- 
stances shall give rise? Beyond the hyperemia, the only phenomenon which 
appears to us after death, there are then, in the brain, other modifications pro- 
duced, which are no longer proved by the scalpel, but by the diversity in the 
nature of the symptoms observed during life. It is not then the cérébral 
congestion, which is the cause of the spécifie symptoms which are produced by 
the différent substances just named ; this congestion is but one of the éléments of 
the morbid state to which they give rise ; a secondary élément, the intensity of 
which does not increase with the severity of the symptoms, and which may even 
be wanting, without the latter ceasing to exist. Is it true that the spécifie 
symptoms produced by each of them, may be explained by the influence which 
each of them exercises over a particular part of the encephalon ? Is it true, for 
instance., that opium acts especially on the cérébral hémisphères, alcohol on the 
cerebellum, belladonna on the tubercula quadrigemina ? This is not the place to 
discuss the value of the physiological experiments, by the aid of which an 
endeavour has been made to establish their spécifie actions. Ail that we should 
say is, that, hitherto, the observations made on man have not sufficiently 
demonstrated thèse results, neither have they disproved or invalidated them. 
However, we shall remark, that in those two cases of poisoning by alcohol which 
we ha-ve above mentioned, the congestion was seated in the cérébral hémisphères, 
as well as in the cerebellum, and that the latter was not the seat of any spécifie 
lésion, at least of one which our présent means of investigation will permit us to 
recognise. Besides, nothing is more variable, as every body knows, than the 
influence exercised on the encephalon by the différent substances whose action we 



80 



CLINIQUE MÉDICALE. 



hère examine. There are, in this respect, individual susceptibilities, instances ol 
vvliich have fallen under the observation of every médical man. 

After having considered some of the external circumstances, which, by the effects 
they produce on the animal economy, may favour the development of cérébral 
hyperemia, let us now direct our attention to the economy itself, and let us try 
whether it vvill not présent certain conditions, which may also have their share in 
the production of encephalic congestions. Among thèse conditions we find some 
states of the brain itself. Thus, forced exertion of the intellect is an unquestionable 
cause of cérébral congestion. We knew a young man, twenty-seven years of âge, 
who, after having devoted himself, for a month unceasingly, to very painful mental 
exertion, fell down suddenly, deprived of consciousness and motion ; he was con- 
sidered as struck with a severe attack of apoplexy ; he was immediately bled ; at 
the end of an hour he recovered the use of his sensés ; he was not paralysed, but 
the limbs on the right and left were as it were benumbed ; he stammered ; 
recovered but with difficulty the thread of his ideas, and he stared at those around 
him with an astonished, and, as it were, stupid air ; thèse phenomena lasted forty- 
eight hours, continually diminishing ; then they disappeared. There remained, 
however, a certain vagueness in his ideas, which did not leave him till he remained 
for some time in the country. Strong mental émotions, have, more than once, pro- 
duced cérébral congestions, some of which have ended fatally*. Certain diseases 
of the brain have also the effect of producing in this organ a congestion, which has 
been erroneously taken for the very cause of the disease ; this is the case with 
epilepsy ; but though not causing the attack itself, the congestion which accom- 
panies or succeeds it, becomes itself, in its turn, the cause of certain symptoms. It 
is on this that the cérébral phenomena seem to dépend, after the fit has terminated ; 
as certain distuibance of the intellect, or else a state of coma which lasts for a 
shorter or longer time, or, again, certain disturbances of motion, as paralysis, or a 
momentary contraction. The congestion which takes place in the brain of epileptic 
patients, during the fit, leaves also traces on the face. Thus, several epileptic 
persons présent, the two or three days after each fit, slight marks of ecchymosis in 
the ski n of the cheeks, and on the conjunctiva. We have seen one, in whom, at 
the end of each attack, a broad livid mark, similar to that produced by a con- 
tusion, covered the forehead and eyelids ; this mark diminished gradually, and 
there was no trace of it at the end of six or seven days. 

Accidentai products developed in the brain, old apoplectic cysts existing in this 
organ, must again be considered as so many thorns, which, from time to time, call 
around them, as around a centre of irritation, an hyperemia variable in intensity 

* The following observations of Dr. Bright, illustrative of the effects of cérébral pressure 
from vascular turgescence, will not be deemed inappropriate in this place. 

The symptoms induced by this state, when it cornes on suddenly, are vertigo, loss of con- 
sciousness, loss of voluntary power, and not unfrequently convulsions ; and hence the difficulty 
of drawing a correct diaguosis between apoplexy from congestion, and certain epileptic attacks. 
There is, in truth, scarcely any précise distinction to be recognised ; the same state of the 
vessels apparently inducing both, and the one passing imperceptibly into the other. The con- 
vulsive nature of the symptoms marks the chief différence, and this probtibly dépends, rather 
upon some original irritability of the brain, or on the part which chiefly suffers from congestion, 
than on any différence in the exciting cause. When cérébral congestion takes place more 
slowly, either as the effect of narcotic poison, or creeping on with the course of years, or as the 
resuit of habituai indulgence, or arising in the progress of disease, it is marked by increasing 
listlessness, by drowsiness, lethargy, and complète coma; while temporary numbness, or loss 
of sensation, or depraved sensation, is often experienced, and towards the close not unfrequently 
convulsion. The first of thèse forms often admits of being greatly and permanently relieved ; 
and though apt to return, may, by care, be warded off for a long period. The latter, that is the 
more slow and the chronic form, is less immediately under the control of medicine; but when 
it dépends on the action of narcotics, will admit of being greatly relieved by treatment, allow- 
ing the effects of the poison to subside, and whenitarises from any definite disease, its rcmoval 

peuds on the cure of the original disorder. — Bright, vol. ii. part 1, p. 198. 



DISEASES OF THE ENCEPHALON. 



81 



and extent ; by the more or less fréquent returns of tins hyperemia are explained 
certain phenomena, intermitting as their cause, which appear at intervais in indivi- 
duals labouring under a cérébral affection of long- standing-, phenomena most 
usually combated by blood-letting. In this way, in particular, may be explained 
those intermitting- convulsions to which several children are subject, in whose brain 
tubercles exist ; it often happens that, when once the convulsions have ceased, there 
no longer remains any cérébral symptom indicating the existence of the accidentai 
product. A remar'kable instance of intermitting phenomena produced by a con- 
stant lésion. The influence exercised by the différent organs, in health or disease, 
on the production or return of cérébral congestion, merits particular attention. 
There is no doubt, for example, that, in those who are predisposed, the process of 
digestion favours the return of thèse congestions ; to a slight degree of those con- 
gestions, we mav attribute the drowsiness exhibited by certain persons after meals. 
With respect to diseases of the stomach, they possess, in certain cases, a manifest 
influence on the development of cérébral congestions. Thus, at ail âges, and par- 
ticularly in infancy, acute gastro-enteritis may be accompanied by symptoms 
announcing the existence of an encephalic hyperemia. The same happens, though 
more seldom, in chronic gastro-enterite. 

The circulatory apparatus may again, by the différent states in which it may 
happen to be, produce différent degrees of cérébral congestion *. There can be no 

* M. Bricheteau, physician to the Hôpital Necker, has, within the last fevv weeks, published 
a volume entitled Clinique Médicale de l'Hôpital Necker. One of the essays contained in 
this work, treats of the influence of the heart and arterial circulation on the brain and its 
functions — on the connection of hypertrophy of the left ventricle with différent diseases of the 
brain : such as cérébral congestions, apoplexy, &c. We shall cite one or two of the cases con- 
tained in this essay : — 

Case 1. — Symptoms of Hypertrophy of the heart — Attack of apoplexy — Death — 
Sanguineous congestion in the vessels and sinuses of the brain — Hypertrophy of the 
left ventricle. 

Louis Germain, fifty-seven years of âge, had been ricketty in his infancy ; conformation of 
his chest bad ; neck short, head large, and countenance high coloured. For several years back 
he had been troubled with palpitations, for which he entered the infirmary of the Hospice de 
Bicêtre, in July 1814. His puise was then fréquent, hard, and irregular; pulsations of the 
heart very extended, sensible to sight and touch ; gênerai bleedings were resorted to ; leeches 
over the région of the heart, &c. The patient was relieved, when, after a hearty meal one 
evening, he felt ail at once a great difficulty of respiration, with loss of consciousness. His 
rnouth was filled with foam, countenance became purple coloured, and he died soon after. 

Post mortem. — Sinuses of the dura mater gorged with black and fluid blood ; the substance 
of the brain very consistent, and the vessels of this viscus very much engorged ; but there was 
no effusion of blood, neither into the cérébral tissue, nor into the ventricles. The left ven- 
tricle of the heart was rather large ; the thickness of its walls more than doubled, and its 
capacity rather contracted than increased. 

Case 2. — Attack of apoplexy— Death — Sanguineous engorgement of the brain and its 
vessels — Hypertrophy of the left ventricle. 

A servant at the Hôtel Dieu, fifty years of âge, of an irritable temper, was for a long time 
troubled with domestic annoyances. His countenance, and particularly his lips, were of a violet- 
red colour : he was found one morning extended on the floor deprived of consciousness ; face 
purple ; eyes fixed, pupils dilated ; respiration stertorous ; puise small and slow ; skin cold and 
insensible : limbs in a state of complète relaxation, &c. The patient was removed into one of 
the wards, where he died in six hours, notwithstanding every attention being paid to him. 

Post mortem. — Vessels of the brain gorged with blood; cérébral substance very much 
injected ; no sanguineous effusion discoverable ; lungs a little gorged with blood ; heart, which 
was of considérable size, presented a marked thickening in the walls of the left ventricle. The 
auriculo-ventricular septum was also very much thickened. 

Case 3. — Symptom of apoplexy — Death — Engorgement of the vessels and of the cérébral 
substance — Hypertrophy of the left ventricle. 

A man, forty-five years old, felt one day ail the symptoms of an attack of apoplexy. He 

G 



B<2 



CLINIQUE MÉDICALE. 



doubt that the variable degrees of force with which the heart drives the blood 
towards the brain, may have an influence on the formation of encephalic hyper- 
emia. As a proof of it, we have often seen persons, in whom the increase of 
violence in the palpitations, with which they were habitually attacked, was con- 
stantly accompanied with vertigo, dizziness, ringing in the ears ; some experienced 
at the extremities of the fingers a sensation of numbness : thèse phenomena 
ceased from the time the palpitations became less violent. Others, who were not 
habitually subject to palpitations, were uniformly seized with violent beating of 
the heart, at the time when the signs of cérébral congestion appeared in them ; 
one of thèse persons told me, that at the moment he commenced to perceive the 
beating of the heart, he felt thèse beatings repeated in the head. Increase in the 
force of the heart's impulse, whether entirely nervous, or owing to hypertrophy of 
this organ, has then a real influence in the production of cérébral congestions ; 
the preceding facts "scarcely admit a doubt of it. But we must guard ourselves 
against concluding, that ail individuals who have palpitations, have, consequently, 
a cérébral congestion ; we have interrogated on this matter several individuals 
attacked with organic disease of the heart, and several of them in answer stated, 
that even at the moment when they were tormented with violent palpitations, they 
had neither dizziness nor vertigo, nor any other sign of encephalic hyperemia. 
On the other hand, among the individuals in whom there exists a tendency to this 
hyperemia, there are several who never have had palpitations, and whose heart 
seems to be in no way diseased. In the five cases of cérébral congestion termin- 
ating in death, which we have recorded, there were but two in whom the heart 
was no longer in the natural state. The other cases of cérébral congestion, which 

entered the Hôtel Dieu on the same day. Every symptom then disappeared, with the excep- 
tion of a little ernbarrassrnent in his speech, and a slight hemiplegia. Puise fréquent and hard: 
heart beat with considérable force. The next day tbe speech was more embarrassed ; face pale 
and swollen; mouth frothy; respiration loud ; action of the heart strong (bleeding from the 
foot, sinapisms, &c). The next day ail the symptoms became worse ; complète hemiplegia, 
respiration stertorous ; action of heart very stfong, irregular; puise small ; death. 

Posi mortem Cérébral substance firni and sound; vessels very much injected, allowing 

some drops of blôod to escape when the organ is sliced : pons Yarolii a little softened ; heart 
large ; walls of the left ventricle thicker than natural, whilst those of the right side are in 
some parts thinned. 

Mr. Bricheteau, who appears from this work to be an irreconcilable foe to vitalism and its 
abettors, and seems determined that the doctrine of the influence of physical laws over vital 
action shall once more take a prominent place in médical science, deduces from his cases, and 
his reflections on them, the following six propositions : — 

1 . The energy with which the heart, more or less approximated to the head, propels the 
blood to the brain, in heakh as well as in disease, exercises an influence on the character, the 
extent of the cérébral functions and even on the instinctive and intellectual faculties. 

2. Hypertrophy of the left ventricle of the heart may produce cérébral congestions, coups 
de sang, attacks of apoplexy by the mère anormal impulse which it communicates to the 
blood ; and this conséquence is far from rare. 

3. The too violent impulse of* the blood upon the brain may cause lacération of the cérébral 
pulp, dilatation and rupture of the vessels, at those points of the brain which receive most of 
them, which rupture is prompt and easy, when thèse vessels are attacked with aneurism. 

4. The essential and indispensable condition for congestion of or effusion into the brain, as a 
conséquence .of hypertrophy of the heart, is the absence of every obstacle to the course of the 
blood, between the left ventricle and the encephalic mass ; such would be, for instance, ossifica- 
tion of the sigmoid valves of the aorta, contraction of the origin of this artery, ossification of the 
small arteries, &c. 

5. Another condition favouring and accelerating the impulse and congestion of blood towards 
the head, and which must hasten its conséquences, is the contracted state of the hypertrophied 
ventricle. Dilatation produces a contrary effect by increasing the volume of the heart, and 
weakening its contractile power. 

6. The knowledge of the influence of hypertrophy of the heart on the development of céré- 
bral congestions and of apoplexies, is. of direct advantage in the practice of medicine, in that it 
points out with certainty the means of preventing and combating those affections, and often of 
preventing their retum. 



DISEASES OF THE EXCEPHALON. 



B3 



have also terminated in death, and have been published by différent auihors, give 
nearly similar results. It has been stated that an obstacle to the course of the 
arterial blood below the arch of the aorta, must produce the same effect as hyper- 
trophy of the left ventricle of the heart, and favour, in the same manner as this 
hypertrophy, the production of encephalic hyperemias. A case has even been 
published, in which an attack of apoplexy was considered referrible to a tumour, 
which compressed the aorta a little below its passage through the diaphragm. If 
such a cause were real, it certainly should have its maximum of influence in cases 
where the aorta, immediately below its arch, was considerably contracted, or even 
obliterated ; now in the cases of th'is kind which have been cited, there is not a 
word either of congestion or cérébral hemorrhage*. 

When any obstacle whatever is opposed to the free return of the blood from 
the brain to the heart, is the resuit of this a tendency to cérébral congestion ? 
There can scarcely be a doubt of it, if it be only considered what a person feels 
towards the brain whose neck is ver y much squeezed ; besides, it has been 
remarked, that one of the efFects of death by strangulation was the production of 
cérébral congestion. Récent researches have, moreover, shown, that the oblité- 
ration of some of the sinuses of the dura mater had, at least more than once, 
coincided with the formation of cérébral congestions and even hemorrhages. Is 
it also on cérébral hemorrhage that the extraordinary phenomena depended, 
which are mentioned in the following case published by Dr. Gintrac, a distin» 
guished physician of Bordeauxf ? A child, four years old, was subject from its 
birth to an affection, which consisted in a momentary suspension of voluntary 
motion. The attack appeared suddenly ; if the child were standing up, the lower 
limbs became flexed, the trunk was reversed, and he fell. In bed the attack 
announced itself only by the complète relaxation into which the locomotive 
apparatus was thrown. During the attack the sensibility was diminished ; the 
sensés were a little dulled ; the eyes remained open, and immoveable ; the hearing 
was preserved ; the intellectual faculties were retained ; but the little patient was 
unable to articulate a syllable. This child died of pneumonia, which came on 
during measles. On opening the body, M. Gintrac found the superior longi- 
tudinal sinus converted into a hard cord, to which veins returned filled with 
coagulated blood. The parietes of this sinus were thick, dense, and of a yellowish 
colour ; they resisted incision, and sounded under the scalpel ; a solid clot filled 
this sinus. No other altération was detectea. 

Another question may be here raised. Should the increase in the rapidity of 
the blood's course, such as is produced by fever, be ranked among the causes 

* In this enumeration of the causes of cérébral congestion, car author seems to have taken 
no notice of the différent pathological states of the lungs, which have a tendency to bring about 
such a resuit. Tbe following observations of Dr. Bright on the subject, will compensate for 
the omission : 

" Tbe conditions of the lungs most apt to produce (cérébral congestion) are : condensation 
from the présence of effused fluid ; changes in the bronchial membrane from chronic inflam- 
mation. Extensive emphysema of the lungs, whether the conséquence of original weakness in 
the structure of those organs, or from violent exertion, or from chronic tkickening of the 
bronchial tubes ; and sanguineous congestion generally dépendent upon some obstruction to the 
free passage of blood through the heart ; and occasionally the changes conséquent on phthisis 
and pneumonia. Many of the most distressing symptoms of bronchitis — the intense headacb, 
the wandering delirium, and the léthargie coma, are undoubtedly dépendent on the state of the 
circulation through the head." — (See vol. 1, pp. 127 to 134.) 

" It is, however, not quite évident wbat part the simple mechanical congestion and what part 
the chemical condition of the blood takes in this morbid train of symptoms : there can be little 
doubt that both thèse causes exert a hurtful influence; for if any organ of the body is calcu- 
lated to feel more injuriously than another the imperfect quality as well as the disproportionate 
quantity of the blood with which it is nourished, it is probablv the brain." — (Dr. Bright, vol. ii. 
p. 221.) 

•f Recueil d'Observations, Bordeaux, 1830. 



84 



CLINIQUE MEDICALE. 



which may produce congestion of the brain ? ïf, in this state ot the System, 
several of the tissues are obviously reddened, may it not be supposed that the 
same thing will happen to the brain ? What is certain is, that we cannot other- 
wise explain the pain of head, vertigo, dazzling, &c, which aceompany every 
access of fever. In children, this morbid state is accompanied with somnolence ; 
there are adults, also, who cannot have a fever, even of moderate severity, without 
becoming extraordinarily drowsy, or without having some delirium, which disap- 
pears according as the fever déclines. Observe again those pandiculations, that 
extrême sensibility to ail external impressions, that fatigue, and dull pains in the 
limbs, that gênerai debility, which aceompany fever when it is well marked ; are 
not ail thèse the phenomena which aceompany certain forms or certain degrees of 
cérébral congestion ? The real existence of the latter cannot be questioned in 
such a case : but far from being the cause of the fébrile disturbance, the congestion 
is often but an efFect of it. The production of cérébral congestions is also 
favoured by the inflammation of the différent organs. The hyperemia, which does 
not constitute inflammation, but which is one of its éléments, may be repeated on 
the brain, and this is observed, both when this inflammation still continues in ail 
îts force, and when it has prematurely disappeared. As an example of the first 
case, we shall instance erysipelas of the face or of the scalp, which sometimes ter- 
minâtes fatally by the cérébral symptoms which are complicated with it, and for 
the explanation of which no other lésion is found on examination, than a greater 
or less hyperemia of the encephalic mass. As an example of the second kind. 
we shall instance what occasionally happens during measles or scarlatina. In 
some children the éruption has scarcely shown itself, when it begins to fade, and 
at the same time the face and eyes become very much injected ; the children 
complain of headach ; they become debilitated ; ail motion is painful to them ; 
they soon become comatose, and die. To account for thèse serious symptoms, 
what do we find in the encephalon ? Sometimes a sero-puruient infiltration of 
the méninges, or a perceptible distension of the ventricles by turbid or limpid 
sérum ; but most frequently nothing more than simple hyperemia, which, in more 
than one case, is itself not very well marked. 

It is, again, common enough to see signs of cérébral congestion corne on during 
the fébrile disturbance which précèdes the éruption of small-pox, measles, or scar- 
latina ; in this fever several children are seized with convulsions, stupor, delirium, 
and thèse phenomena vanish as soon as the éruption appears. There are other 
cases where cérébral congestion recognises for its cause neither intense fébrile 
disturbance nor an inflammation : but where it is connected with other conges- 
tions which occur in différent organs, and which alternate one with another. 
Sometimes this tendency of several parts to hyperemia is connected with a gênerai 
state of plethora ; sometimes the latter does not exist, and there is observed a 
succession of local plethoras, which cannot be explained by the apparent constitu- 
tion of the individual. We have more than once met persons, in whom dizziness, 
dyspnœa, palpitations showed themselves by turns. We have seen a woman who 
presented a succession of hyperemias. She began by complaining, for fifteen 
days, of a violent headach, accompanied by continuai dazzling, vertigo, disagree- 
able noise in her ears ; she staggered in walking, as if she were drunk. Thèse 
signs of cérébral congestion disappeared, at the same time that there came on an 
abundant epistaxis, which was renewed for several successive days. Scarcely did 
this epistaxis cease, when she began to feel pains towards the loins, the lower ex- 
tremities became numbed, and there soon appeared a menorrhagia, which lasted 
for thirty hours. The patient, being thirty-seven years of âge, had not had her 
menses for the last three months ; it was nearly at the usual period of their return 
that the menorrhagia took place. After this phenomenon, there was no more 
appearance of hyperemia towards any organ for a month. At the end of that 
time the menses did not appear ; but without cough, or preceding dyspnœa, some 



DISEASES OF THE BRAIN. 



85 



blood was expectorated in a quantity large enough to fîll the fourth of an ordinary 
glass, After this hemoptysis had ceased, signs of cérébral congestion re-appeared, 
and they continued with variable degrees of intensity for twenty days ; at the end 
of this time a new scène presented itself : the cérébral symptoms disappeared ; 
but the patient voided pure blood by the bowels, and this new flux went on for 
twelve days : tvvice or thrice every twenty-four hours she felt a slight colicky 
pain, which caused her to go to stool, and every time she went she passed from a 
fourth to half a glass of blood ; on some days even the loss of blood was still 
more considérable. This internai hemorrhage lasted till the time of her menses 
came, which did not then appear. They did corne the following period, but in 
the form of a hemorrhage so copious as to render bleeding necessary. From this 
period her health was re-established ; menstruation became regular ; only some 
days before they appeared, she complained of headach and some attacks of 
vertigo ; she had flushes of heat in the face, and was troubled with palpitations. 
We shall now cite a case in which the congestion, primarily seated in the brain, 
was then removed to the lungs, and became immediately fatal in conséquence of 
the hemorrhage it produced. A man, fifty years of âge, entered the Maison 
Royale de Santé, with ail the signs characterising great cérébral congestion : this 
was not removed by a bleeding. Ail at once the patient was seized with extrême 
dyspnoea, which continued to increase, and he died at the end of four hours. On 
opening the body we found the cérébral mass gorged with blood ; no other lésion 
in the brain. But in the two lungs there were found hard and black masses, which 
presented ail the characters of the lésion known by the name of pulmonary 
apoplexy. The walls of the heart were hypertrophied*. In the preceding case 
we sought and found the causes of cérébral congestion in the influence of the 
forces, whether mechanical or vital, which préside over the circulation. Are thèse 
congestions also influenced by the différent degrees of activity of sanguefaction : 
that is, by the greater or less energy of the force which makes the blood ? In 
other words, what is the influence exercised, either by a state of gênerai plethora, 
or by a contrary state, on the production of cérébral hyperemia ? We shall now 
consider that point. 

It is undeniable that, in many individuals, a state of gênerai plethora coincides 
with the appearance of the symptoms indicating the existence of cérébral conges- 
tion ; but it is far from being so in ail cases. There are even individuals in whom 
this congestion appears, at the very time that they arrived at a remarkable state 
of anémia. We hâve just seen at the La Pitié, a woman labouring under cancer of 
the utérus, and very much exhausted in conséquence of the great hemorrhages she 
constantly had from the utérus ; yet, she has just died from cérébral hemorrhage. 
We shall conclude this inquiry by some considérations regarding the part which 
muscular action may have on the production of cérébral congestions. There is no 
doubt but violent exertion will pre-dispose to it. The attacks of vertigo, to which 
the action of turning round gives rise, were followed, in the case which we shall 
now cite, by phenomena usually attributed to cérébral congestion. 

In the course of the month of December, a law student was at a public bail, 
where he waltzed for some time with considérable ardour ; he fell down suddenly 
deprived of sensation and motion. Notwithstanding every attention having been 
paid to him, bleeding, &c. — he died. We learned that he had enjoyed excellent 
health, and had just made a very hearty meal. The body was opened thirty-six 
hours after death. In the cranium the vessels of the membrane were found gorged 
with blood, and the cérébral substance was as it were covered with sand {sablée) 
throughout ail its extent. The lungs were gorged with an enormous quantity of 
black, viscid blood. The heart, which was large, presented no lésion in other 

* This is not the only case where we have seen pulmonary apoplexy without spitting of 
blood. See our next two volumes en the subject. 



86 



CLINIQUE MÉDICALE. 



respects ; its right cavities were filled with blood, those on the left empty, as also 
the aorta. In the abdomen there was nothing else remarkable, but a very con- 
sidérable venous congestion of the intestinal parietes, and considérable sariguineous 
engorgement of the liver and spleen. It does not appear to us, as has been 
frequently asserted, that cérébral congestions are more common at an advanced 
âge. We hâve seen numerous instances of them in young persons ; it is wrong to 
judge of their frequency at the différent âges from that of cérébral hemorrhages, 
which become common only at a considérable advanced period of life ; that cer- 
tainly is not the case with simple hyperemia of the brain. The facts cited prove 
the thing sufBciently. 

The duration of cérébral congestions varies according to each of their forms, 
and, even in thèse forms, there are still, in this respect, very great différences. 
Sometimes the congestion returns incessantly, and that during several months, and 
even during several years. We have seen individuals who, for almost ail their 
life, were tormented with it. It not seldom is suspended for a shorter or longer 
period, and then returns under the influence of causes which are appréciable or 
not. We knew a man, who, during several years, experienced at the close of every 
winter, the symptoms of an intense cérébral congestion. Thèse symptoms con- 
tinued for fifteen days, when they disappeared in order to appear again the 
following year at the same period. Several authors have spoken of intermitting 
apoplexies, which, in their return, observed the same regularity as the fevers of 
this name, and presented themselves with the same types. We observed, some 
years ago, a very remarkable case of this kind, which we shall here record. A 
woman, sixty-three years of âge, habitually enjoyed tolerably good health, when, 
one morning on getting up, she was suddenly seized with great illness, vomiting, 
and a violent pain of the head ; a quarter of an hour after thèse symptoms 
appeared, she uttered a loud scream, and fell, deprived of consciousness. We 
visited the patient abouthalf an hour after the fall ; wefindherplungedintoaprofound 
coma ; eyes shut, pupils large and immoveable, but the eyelids are raised, and when 
the conjunctiva is touched with the end of the finger, there is scarcely produced a 
slight contraction of the eyelids, and the patient makes no effort to withdraw her- 
self from this contact. Face injected ; commissures of the lips not affected ; 
tongue cannot be seen ; the four extremities are in a state of complète relaxation, 
and the sensibility of the skin covering them appears abolished. The puise strong 
and free from frequency ; heart beats strongly. This woman appears to us struck 
with cérébral hemorrhage, considérable enough to engage both hémisphères ; 
we immediately bled her, and had her removed to La Charité. After passing 
the most unfavourable prognosis on her state, what was our astonishment, when 
the next morning, at the visiting time, we found her sitting up in the bed, possess- 
ing ail her intelligence, and enjoying ail the freedom of motion. What occurred 
to her was as follows : — After the bleeding no amendment manifested itself ; she 
continued plunged in coma till towards six o'clock in the evening ; when she 
came to herself, and according to the account of the sister of the ward, she no 
longer appeared ill. From this we thought that the woman had nothing but a 
violent cérébral congestion, or which is called coup de sang. 

The day passed on, and when we saw her the next day, she asked permission 
to leave the hospital ; but before returning home, she was to pass through 
new sufferings. We had scarcely left her (it was then seven o'clock in the 
morning) when she was seized with vomiting, as on the day before ; then she 
suddenly lost ail sensation and motion, and the same symptoms which were 
observed on her before entering the hospital now returned. This time they 
lasted longer ; in the evening they still continued ; no amendment at night ; and 
when we saw her again, at seven in the morning, she was still in a profound 
coma. However, she was bled ; leeches were applied to her neck. Up to one 
o'clock in the afternoon no change appeared ; then the patient opened her eyes, 



DISEASES OF THE ENCEPÏIALON 



87 



spoke, recovered her intellects, moved her limbs with ease, and a second time was 
quite wèll. She then lef't the hospital. We visit her at her own house ; she is 
quite well, yet she stammers a little, and there is a slight degree of stupor in her 
countenance. We do not yet suspect an intermitting apoplexy, and no particular 
médicinal directions were given. The folio wing morning the same symptoras 
return. They continue the entire day with frightful intensity, and last thirty-five 
hours ; then, as on the two preceding occasions, the patient cornes to herself, and 
recovers the freedom of her motions ; but her intellect is somewhat dull, and she 
speaks not without difficulty. We then asked ourselves, whether we had not to 
do with one of those diseases described under the name of masked intermittent 
fevers ? Ten or eleven hours still remained till the period when the next attack 
was to take place. We instantly administered, by the mouth, twenty grains of 
sulphate of quinine ; we administered the same dose of this sait in a starch injection, 
and we placed under each axilla, in each inguinal région, tweîve grains of the 
same sait, mixed up with some fresh butter. We await with anxiety for the 
patient, and also with ardent feelings of scientifîc curiosity for what will happen 
the folio wing morning. Towards six o'clock no symptom developed itself. Thus 
the fit is at least retarded, and there is reason to think that, if it return, it will be 
less intense. Towards noon the patient begins to feel a shivering, which she had 
not experienced on the preceding occasions ; violent headach supervened without 
vomiting ; soon after some convulsive movements agitate the muscles of the face ; 
her intelligence becomes disturbed ; movements of the limbs not yet changed ; 
puise accelerated ; thèse phenomena succeed each other in the space of half an 
hour ; then they are replaced by a state of coma, which lasts for about two hours, 
and then goes off. The patient then continues for some time as if benumbed ; 
her skin becomes covered with a little moisture, and again she appears cured. 
Sulphate of quinine was immediately administered in the same dose, and after the 
same manner, as on the day before. No symptoms occurred after. 

This fact furnishes a very remarkable instance of an intermittent cérébral con- 
gestion, which assumed a tertian type, and which was completely put a stop 
to by quinquina. Observe, that the third fit was much more severe than the 
preceding two. The sulphate of quinine was administered, and the next fit 
becomes, on the one hand, less severe and of less duration ; and, on the other 
hand, it is remarkably modified in the nature of its symptoms. For the first time, 
some shivering marks its onset ; and for the first time, also, its termination is 
accompanied with some perspiration. Thus, in becoming less severe, the fit 

approaches nearer in its symptoms to a fit of ordinary intermittent fever. We 

have had an opportunity of observing, at the Maison Royale de Santé, another 
case of bad intermittent fever, the prevailing symptom of which was profound 
coma. The individual attacked with it was still a young man, residing in one of 
the streets adjoining that of the Faubourg Saint-Denis. The quinquina, given 
only between the second and third fit, prevented not the return of the latter, 
during which he died. The fever presented the tertian type. On opening the 
body we discovered no other lésion than a considérable increase in the size of the 
spleen, and an intense hyperemia, not only of the brain, but of the lung, liver, and 
digestive tube. The grey substance of the circumvolutions struck us by its brown 
colour. This colour, which appeared to us the mark of very intense congestion 
of the circumvolutions, was noted by Dr. Bailly in the numerous autopsies which 
he made of persons who died at Rome with the symptoms of comatose inter- 
mittent fever of a typhoid character *. The cases recorded by the physician 

now mentioned point out in thèse fevers several of the forms of cérébral congestion 
already marked out by us. But in none do we find the genuine apoplectic form, 

* Traité Antomico- Pathologique des fièvres intermittentes, simples et pernicieuses, 
observées à l'Hôpital du Saint Esprit de Rome. Par E. M. Bailly. 



88 



CLINIQUE MEDICALE. 



such as occurred in the woman whose case we gave a littie while ago. We see 
in M. Bailly's cases that sometimes the coma supervened from the first fit, and 
went on increasing in intensity in the following fits ; and that sometimes, on the 
contrary, it was only at the end of a certain number of fits that the intermittent 
fever, till then mild, assumed ail at once a typhoid character, with prédominance 
of encephalic symptoms. The following case of M. Bailly's is peculiarly interesting 
in this respect. 

A man, thirty years of age,had been labouring for some time under tertian ague ; 
he came to the hcspital the 2nd of July, 1822. The 3rd, he had a slight fit, after 
which he took two ounces of quinquina. On the 4th, towards noon, he walked 
about the ward, felt himself very well, and joked with the other patients. Suddenly 
he was seized with a violent shivering, which was succeeded by a very intense 
fever, during which he had contraction and flexion of the fore-arm on the arm, and 
profound coma ; he died six hours after the fit. The only lésion found in the 
encephalon was a very considérable injection of the arachnoid, and a deeper colour 
than usual of the grey substance of the brain. It must not be supposed that in 
ail the cases of this kind the cure can never take place except on condition of 
giving the quinquina. Thus Frédéric Hoffman reports the remarkable case of a 
young man, twenty-six years old, who had six days in succession, every morning, 
ail the symptoms characterising an attack of apoplexy. On the seventh day thèse 
symptoms did not return, and they did not appear again though nothing was done 
to stop their return. 

Whatever may be the form and progress of cérébral congestion, its termination 
is far from being always the same. It may prove fatal, either alone, without any 
other complication, or after having produced in the brain différent lésions, and 
more especially either a hemorrhage or a softening. We shall presently see that 
it is often the precursor of one or other of those affections. 

Cérébral congestion terminâtes most frequently in a favourable manner ; but its 
return may be dreaded, or, at some future period, a more dangerous disease. It 
sometimes happens, that certain phenomena, particularly fluxes, coincide with its 
disappearance, and appear to contribute to it. We have seen a woman, who, for 
about a month, was tormented with vertigo and other symptoms, which caused us 
to apprehend an attack of apoplexy ; repeated bleedings, a blister applied to the 
nape of the neck, exercised no remarkable influence on those symptoms. At last 
she was seized on a sudden with copious diarrhœa ; she had, in forty-eight hours, 
fifteen stools, constituted principally of bile ; at the end of this évacuation, which 
was scarcely accompanied with any colic, the cérébral symptoms disappeared. 

We have seen another person, thirty-six years old, who from five to six weeks, 
had had headach, vertigo, ringing of the ears : at the same time, he experienced 
in the left side of the face, as well as in the left extremities, an almost continuai 
formication ; at intervais his intelligence became dull, he stammered and tottered, 
when walking, as if intoxicated ; at intervais also his mouth became slightly dragged 
to one side ; copious bleeding, various révulsives applied to the skin, as well as to 
the digestive canal, were resorted to without any benefit. At last an epistaxis 
came on, during which the patient lost at least two pounds of blood ; after this 
hemorrhage, he no longer felt anything with respect to the head, and every sign 
of cérébral congestion disappeared. 

Lancisi mentions a case similar to the one now cited ; it was that of a man 
seventy years of âge, who for a month presented in a very high degree the dif- 
férent symptoms of intense cérébral congestion ; at the end of this time he had an 
epistaxis, in which he lost eleven ounces of blood, and from that time out he was 
cured. To thèse facts, we ad'd the following, which we witnessed : — A woman, 

* Oper. cit. p. 155. 



DISEASES OF THE ENCEPHALON. 



89 



thirty-five years of âge, vvas attacked for some titne back with a tic douloureux of 
the face ; the neuralgic pains suddenly ceas-ed, but were succeeded by a violent 
pain of head, and a giddiness so intense that the patient could no longer stand up ; 
she had at the same time very painful nausea, and vomited twice a considérable 
quantity of yellow bile. This lasted for two hours ; there was then seen to flow 
through the nasal fossae, not blood, but such a quantity of serous liquid, that 
several handkerchiefs were soon moistened by it. This discharge lasted for some 
hours, and when it ceased the cérébral symptoms disappeared. 

It would seem that cérébral congestion should be one of the diseases against 
which copious blood-letting must certainly succeed. And so it happens in a con- 
sidérable number of cases : very often hâve we seen headach, dizziness, tinnitus 
aurium, numbness of the limbs, &c, disappear ail at once after a copious bleeding. 
But more than once, also, lias this remedy been resorted to in vain ; the signs of 
congestion did not disappear ; or else, if they diminished or disappeared immedi- 
ately after the vein was opened, they are soon reproduced, however, with as much 
intensity as before ; in some cases too they are rendered more severe, according 
as the individual has been weakened by repeated bleedings. Nor have we seen, 
under such circumstances, that bleeding from the foot possessed any real advan- 
tage over bleeding from the arm ; besides, we are inclined to think that opening 
the vein generally produced more efFect than the application of leeches to the neck 
or anus. 

There are some rare cases in which not only no relief follows the bleeding, but 
where it produces in the System such a disturbance, that, under its influence, the 
simple signs of a cérébral congestion are changed into those of an attack of apo- 
plexy, as may be seen in the following case : — A carpenter, seventy-four years of 
âge, tolerably fat, with short neck, muscles well developed, and presenting the 
signs of hypertrophy of the left ventricle of the heart, (puise hard and vibrating, 
strong impulse of the heart's action, which is heard only over a very small extent of 
surface,) experienced for some time back constant dizziness, when he entered the 
La Charité, in the month of February, 1821. His left extremities he felt to be 
heavy and benumbed ; he was bled from the foot. Whilst the blood was flowing, 
the patient suddenly lost ail consciousness ; the extremities of the left side became 
rigid for some seconds ; they then fell into a state of complète resolution. At the 
same time, the left commissure of the lips was drawn down, the mouth became 
filled with foam, and the respiration stertorous. At the end of an hour conscious- 
ness returned. The following morning, the mouth was straight; the intelligence 
was restored ; but the extremities of the left side were completely paralysed. 
During the twelve following days this paralysis continued ; (leeches to the neck, 
purgative lavements ; blister to the nape of the neck ;) it was then completely 
removed, and the patient was soon able to go out, no longer retaining any traces 
of it. 

For a certain number of years back, it is but with very great reserve that pur- 
gatives have been employed in the treatment of cérébral congestions ; hence it 
happens that no advantageous resuit is obtained from them, in conséquence of the 
inertness and want of activity in those which have been employed. We can state 
positively that we have derived the greatest benefit from this plan of treatment in 
more than one case of cérébral congestion ; but the purgatives which we adminis- 
tered were strong enough to produce from ten to twelve or fifteen évacuations in 
twenty-four hours. Some persons, with whom blood-letting had been employed 
unsuccessfully, were thus cured by puigatives. At this very moment there is in 
the wards of the La Pitié a man, who for several years back has been seized from 
time to time with violent pain of head, great dizziness, and palpitations. At first 
we had him bled 5 still thèse symptoms continued ; we gave him two drops of croton 
oil, which pro'.uced very copious alvine déjections. The following' day he neither 
had headach, nor vertigo, nor palpitations. For several days thèse symptoms did 



no 



CLINIQUE MEDICALE. 



not appear, they then returned. Two drops of croton oil were again prescribed, 
and after some copious évacuations which they produced, the signs of cérébral 
congestion, as well as the palpitations, ceased as rapidly as the first time. Eight 
days passed on without the patient complaining of any thing ; and then the pain 
of head and dizziness again returned, without being accompanied with palpitations. 
This time the patient himself entreated us to prescribe the croton oil for him again- 
We acceded to his request, and it was attended with the same success as on the 
two former occasions. This individual has not complained since, and he is now 
leaving the hospital perfectly restored. The three différent doses of croton oil do 
not appear to have distressed either his stomach or intestines. Twenty-four hours 
after the administration of this medicine, the diarrhœa which it produced ceased 
spontaneously ; the patient asked for something to eat ; the abdomen presented 
not the least trace of irritation. 

We should be so much the more inclined to employ a révulsive treatment for 
the cure of cérébral congestion, inasmuch as we have more than once seen its 
symptoms disappear only when a flux came to be established spontaneously on 
différent organs. Every one knows that the absence of the menses in women is 
often accompanied with signs of sanguineous congestion towards the brain, which 
do not cease till the menses reappear. Several women expérience every month, 
two or three days before their time, which in other respects is sufficiently regular, 
vertigo, dazzling, flushes of heat in the face, &c, and there is often observed at 
the same time a difEculty of respiration, which also indicates a congestion in the 
respiratory tube. The disappearanee of hemorrhoids in the two sexes has occa- 
sionally given rise to the same symptoms. *We have seen, at the La Pitié, a 
middle-aged man, who for four consécutive years, was attacked every summer 
(towards the month of July) with severe dizziness, which on every occasion 
ceased at the same time that an abundant discharge of blood by the rectum took 
place. This blood was exhaled by the mucous membrane ; there was no vestige 
of hemorrhoids in this case. 

To thèse facts we shall add another, observed by ourselves at the La Charité, 
in which very serious cérébral symptoms, which lasted for several years, suddenly 
disappeared, at the same time that other organs became affected. A woman, 
fifty-six years of âge, entered the La Charité in September, 1828. She expe- 
rienced every day, for the last fourteen years, nervous symptoms resembling 
those which characterise an attack of epilepsy. The first few days of her entering 
We ascertained their real nature. She has every day two of thèse attacks. For 
several years back she has also had at différent times hematemesis, and discharges 
of blood from the utérus. In other respects she appears in good health ; the 
digestive functions not altered ; no lésion of the utérus discoverable. Copious 
bleeding was employed, which had not the slightest influence on the disease. 
Ten days after coming to the hospital she was seized with acute pains in the sole 
of the foot ; the entire skin soon became the seat of painful pricking sensations ; 
we soon discovered her to be attacked by the épidémie which then prevailed in 
Paris. But, what was very extraordinary, the moment this affection developed 
itself, the epileptic fits, which we saw renewed every day since she entered the 
hospital, and which had continued in this quotidian form for the last fourteen 
years, disappeared. The symptoms of the épidémie continued for the twelve 
days following ; and during ail this time not the least trace of the cérébral 
affection. Then a new séries of phenomena is presented — namely, hemorrhages, 
which appear alternately on the mucous membranes ; successively, and at dif- 
férent times, blood flows in great abundance from the nasal fossa?, the stomach, 
bronchi, vagina, and rectum. The différent organs, which alternately become the 
seat of thèse hemorrhages, no longer manifest any disturbance from the instant 
the hemorrhage leaves them to go elsewhere. Whilst thèse différent fluxes cf 
blood are taking place, the symptoms of the épidémie are first mitigated and then 



DISEASES OF THE ENCEPHALON. 



91 



drsappear ; the epileptic. attacks are not reproduced ; the heinorrhages cease one 
after another, and the woman leaves the hospital in perfect health. So rapid a 
succession of phenomena, affecting so many différent organs, is very remarkable ; 
and it is realty astonishing to see alarming nervous symptorns disappear so 
rapidly, the continuance of which for a length of years, seemed to announce that 
they depended on a deep-seated lésion of the brain or its coverings. 

We have novv sketched the principal traits of the history of cérébral conges- 
tions ; before proceeding, one serious question arrests us, it is this : are the 
symptorns which characterise the différent forms of cérébral congestions, con- 
nected in ail cases with the afflux of too great a quantity of blood to the brain ? 
do they dépend solely on that cause ? are they not sometimes seen as the effect 
of a quite opposite state of the nervous centres, or in other words, of their 
anémia. 

It is a law in pathology that, in every organ, the diminution of the quantity of 
blood which normally it should contain, produces functional disturbances, as well 
as the présence of an excessive quantity of blood. And what is more, in both 
cases thèse functional disturbances are precisely similar. Let impoverished or 
too thin blood traverse, for instance, the cavities of the heart, palpitations will be 
the resuit, just as if too much blood distended it. Dyspncea cornes on equally 
soon, whether the lung be the seat of a greater or less hyperemia, or whether the 
air, on entering the pulmonary vesicles, does not find enough of blood there to 
arterialise. Dyspnœa equally recognises for its causes, anormal paleness of the 
mucous membrane of the stomach, and a more or less intense sanguineous injec- 
tion of this membrane ; we might multiply such examples ad infinition. The nervous 
centres might afford a considérable number of them, Thus we have found, more 
than once, the brain and its membranes completely bloodless in children who 
died in the midst of convulsions ; we have also seen the state of coma, in which 
many of their diseases terminate, coincide with remarkable paleness of the nervous 
centres. Several times also in adults we have been struck with the complète 
absence of colour in the brain, perceptible principally in its grey substance, in 
cases wherein during life cérébral phenomena had taken place, such as delirium, 
convulsive movements, coma. Do not animais also who are bled to death 
exhibit symptorns of this description ? 

We have often seen individuals who seemed to be completely anémie ; their 
face was extremely pale, and their entire skin presented a colour like to that of 
wax ; thèse persons could not walk without panting very violently ; even when 
in a state of rest their breathing was short. They were harassed with palpita- 
tions ; they digested with pain to themselves ; some even rejected the little food 
they put into their stomach. At the same time they had headach, giddiness, 
vertigo, tinnitus aurium ; some even experienced, either at intervais or con- 
tinually, numbness in the limbs ; others had before their eyes a thick mist ; or 
else they were tormented with hallucinations of vision or of hearing. Thèse 
persons had experienced for a long time back copious hemorrhages in différent 
parts, either by the nasal fossse, or by the rectum, or the utérus, and they 
habitually presented the phenomena which several persons momentarily exhibit 
when they are just after being bled. It must be admitted that the brain in such 
cases is disturbed in its functions, because it is no longer suitably stirnulated or 
nourished by the too poor or too diluted blood which the heart sends to it. In 
thèse circumstances it is oftentimes only necessary that a certain time should have 
elapsed since the cessation of the hemorrhage, when, according as the blood is 
renewed, the phenomena occasioned by its subtraction are seen to disappear. 
But they often continue ; digestion in particular remains so laborious, that the 
System is unable to repair its losses. It is then that we have more than once 
employed with decided success the préparations of iron, and particularly the sub- 
carbonate. Under the influence of this medicine, we have seen the digestion re- 



92 



CLINIQUE MÉDICALE. 



established, palpitations cease, the respiration become free, and at the same time 
the cérébral symptoms disappear. Thus the same symptoms, according to the 
diversity of the cause producing them, yield equally, sometimes to blood-letting, 
sometimes to iron taken into the stomach every day in the dose of from ten to 
thirty grains and even more. 

Without there being any ioss of blood, this fluid may be modified in such a way, 
as to give rise to the disease known by the name of chlorosis ; in such case, the 
organs receive their stimulus and nourishment from impoverished blood. Thus, 
they are disturbed in their functions in the same manner as if a hemorrhage had 
taken place. In young chlorotic girls, the functions of digestion, circulation, and 
respiration are modified, just as in persons whohave been subjected to great losses 
of blood ; with such persons also, the innervation évinces its suffering by symptoms 
and phenomena of the same kind, and iron is here also one of the best means to 
be employed. 

If now, we leave the simple observation of facts, in order to endeavour to 
account for them, we shall soon satisfy ourselves of the insufficiency of the 
Brunonian dicholomy to explain the symptoms which supervene after cérébral 
hyperemia or anémia, and which are most frequently similar. Thèse symptoms 
do not necessarily indicate either the hypersthenic, or the asthénie state. They 
may be owing to a mere perversion of the cérébral influence, a perversion which 
is no more connected with an excess, than with a deficiency of life, and which 
results from this circumstance, that the biain must live another life for this sole 
reason, that it no longer receives its normal quantity of blood, and not merely 
because it is then less excited. 

But this is not ail : when we have referred the symptoms to a hyperemia in 
one case, and to anémia in another, be we come to the bottom of the subject ? By 
no means ; for this hyperemia and this anémia are themselves mere effects, which, 
a thing very remarkable, the same influence can often produce : thus, by an 
émotion of the mind, the skin of the face becomes red in one person, and pale in 
another. 

In the nervous centres, as elsewhere, before the production of hyperemia or 
anémia, we must conceive a primary modification of the force, whatever it is, which 
subjects the cérébral circulation to certain rules. In the midst of thèse numerous 
currents, of thèse oscillations of globules, which pass within the organic tissues, 
how many causes constantly presented, and whose influence is entirely unknown 
to us, may dérange a current, and modify the distribution of the globules. Thus, 
either electricity, or the hygrométrie state, &c, must act on them, as so many 
forces, or, in other words, as so many causes of phenomena. 

When we thus examine minutely the grounds of the question, we soon see that 
hyperemia and anémia, in the brain, as in other parts, are themselves but secondary 
phenomena— mere effects. But thèse effects, inconstant and variable, do not 
necessarily follow the action of the cause ; they may be wanting, and yet the 
symptoms will still continue ; for they dépend less on the state of cérébral 
hyperemia or anémia, than on the organic modification which précèdes them, and 
which causes them. Thus, our post mortem examinations show us, for the expia- 
nation of identical symptoms, sometimes a state of hyperemia, sometimes a state of 
anémia, sometimes nothing unusual in the quantity of blood contained in the 
brain ; and in this brain, moreover, no lésion appréciable by our présent means of 
investigation ; the reason is, because thèse means do not show us ail ; by them 
we as yet discover nothing but effects ; the material modification which incontest- 
ably précèdes the latter, requires not their production in order that disturbance 
may take place in the functions of the organ. However, once produced, the 
différent lésions which the présent state of anatomy is calculated to reveal, may 
give rise to phenomena which dépend on them alone, and which establish their 
diagnosis. Thus, the disturbances of motion, sensation, and intelligence, which 



DISEASES OF THE ENCEPHALON. 



93 



accompany a hemorrhage or softening of the brain, have no longer the same 
physiognomy as in the case where they are cormected with simple cérébral hyper- 
emia, and as in the case where they are not explained by any of the lésions which 
our scalpel can reveal to us. 

It is obvious of what importance thèse considérations are for the solution of 
more than one problem of therapeutics. It is only by admitting, for example, that 
every case of delirium is not the resuit of cérébral congestion, that we can con- 
ceive the truly marvellous effects produced by opium in certain cases of delirium, 
called nervous delirium, to which those persons in particular are subject, who take 
alcoholic liquor to excess, The following case, in point, recently presented itself 
to us. A man, of middle âge, subject to intoxication, entered the La Pitié with 
erysipelas of the face. When this inflammation was on the point of subsiding, the 
patient was seized ail at once with furious delirium ; he was leeched and bled from 
the arm without any advantage. I determined to try the use of opium. I pre- 
scribed forty drops of Rousseau's laudanum in a Ave ounce mixture, and recom- 
mended a spoonful to be given him every hour. This direction was complied with ; 
still no amendment took place, and the next morning the delirium continued in ail 
its intensity. I still am not discouraged, and I add a drachm {un gros) of Rousseau's 
laudanum to the same quantity of liquid. After he had taken it ail, the patient 
fell into a profound and tranquil sleep, and when he awoke, he was in full pos- 
session of his reason. The same day he commenced to eat, and left the hospital, 
two days after, in good heaîth. 



SECOND ORDER. 

OBSERVATIONS ON HEMORRHAGE OF THE CEREBRAL HEMISPHERES. 

The important and numerous works published from the time of Wepfer up to 
the présent day on cérébral hemorrhage, have thrown great light on most points 
of the history of this malady ; however, in proportion as science progresses, it 
frequently calls in question many of the accredited opinions, and constantly 
requires that new facts should submit them to their controul. Such was our end 
in publishing the cases now about to be read, and the recapitulation which follows 
them. Among the cases we have collected, we thought it right, more particularly 
to make known those in which the hemorrhage is limited to certain circumscribed 
portions of the cérébral hémisphères, contrasting them with those in which the 
hemorrhage had its seat simuïtaneously in several parts of thèse hémisphères, 
This is the point of view which has determined the order according to which our 
cases are ranged. 



SECTION I. 

PARTICULAR CASES. 

Case l. — Clots of blood scattered through the substance qf the cérébral circumvolutions 
— Sudden loss of intelligence — General resolution ofthe extremities — Death in the 
midst of asiate of comafifty hour s after the first appearance. 
A man, forty-nine years of âge, was brought to the Maison de Santé (Septem- 

ber 1830), in the following state : state of coma from which nothing could arouse 



94 



CLINIQUE MÉDICALE. 



him ; he resembles a person plunged into a deep sleep ; inspiratory movements 
succeed each other at long intervais ; the four extremities, when raised, fall as inert 
masses ; severe pinching has not the effect of making them move, nor is the 
expression of the countenance modified by it. Lips not dragged ; tongue cannot 
be seen ; puise only fifty-seven ; such was his state on the morning at the visiting 
hour. We were told, that having been subject for some tinie to some slight 
transient disturbance in his ideas, this man, who had used alcoholic liquor to 
excess, had had violent dizziness of the head the day before we saw him ; then 
towards two o'clock, he suddenly lost the faculty of speaking, seeing, and hearing, 
and at four o'clock he fell into the state just described. Such was the account we 
got. A copious bleeding was prescribed, sinapisms to the legs, and diluent drinks. 
The following morning his state was the same, except that the inspiratory move- 
ments, which were so very slow the day before, were accelerated, without the 
frequency of the puise being increased. Thirty leeches were applied to the neck, 
and the head was covered with a bladder full of ice. In the course of the 
day the respiration became more and more embarrassed, and the patient died at 
four o'clock in the evening. 

Post Mortem— Considérable injection of the vessels of the méninges. On each 
side, over the convexity of the hémisphères, the circumvolutions presented a sort 
of fluctuation in five or six points, each the size of a ten sous pièce. We had 
scarceiy removed from one to two lines of the cérébral substance over thèse fluctu- 
ating points, when we found, immediatelybeneath it, some blood slightly coagulated, 
contained in a small cavfefc capable of containing a large hazel nut. Around this 
cavity, the parietes of which were of a yellow colour, the cérébral tissue presented 
a bright red dotted appearance, but without any change of consistence. There 
were also from seven to eight small clots seated in the circumvolutions of the 
upper surface of the right hémisphère, and nearly as many on the left. We 
found no other lésion in the encephalon. Walls of the heart were obviously 
hypertrophied. 

Remaries.— This case présents the very rare example of a case of hemorrhage of 
the cérébral circumvolutions without complication of any other effusion of blood 
into the remainder of the encephalon*. The individual who was the subject of 
it, had nearly the same symptoms as those which are usually produced by a 
violent hemorrhage taking place in the substance of one of the hémisphères. 
Dizziness preceded the attack of apoplexy : the latter presented as a prédominant 
phenomenon, the suspension of the sensés, and of the faculty of speech ; then there 
came on a state of coma, in which the patient died, fifty hours only after the 
appearance of the first symptoms. The respiration was accelerated only towards 
the termination, and the puise continued free from frequency up to the last. The 
absence of hemiplegia is accounted for by the présence of the apoplectic clots 
(foyers) in both hémisphères. We shall not forget to remark, that around each 
of thèse clots, there existed, for the space of some lines, a bright red injection of 
the cérébral pulp. The nature of the effused blood attested the récent date of the 
hemorrhage. 

Thus simple compression of the most superficial part of some cérébral circum- 
volutions is suflicient to abolish intelligence, to suspend the exercise of the sensés 
and of speech, and to produce a coma which proved rapidly fatal. We find the 
immoderate use of alcoholic liquors a predisposing cause of cérébral hemorrhage. 
The commencing altération of the intellectual faculties, observed before the attack, 
is not accounted for by the state of the brain. The coïncidence of hypert'rophy of 
the heart and of cérébral hemorrhage should not be forgotten. 

* In the second volume of our Pathological Anatomy, another case of simple hemorrhage 
of the circumvolutions is cited, found in an individual who died suddenly after strong cerehral 
excitemcnt. The reader is rcquested to compare the two cases. 



DISEASES OF THE ENCEPHALON. 



95 



Case 2. — Cérébral circumvolutions transformed into a sort of erectile tissue — S mail 
sanguineons effusions into this tissue — Varicose dilatation of the veins of the pia 
mater — Perforation of one of them — Attack of apoplexy : death at the end of 
twenty-four hours — Gangrené of the lung. 

A wooian, fifty years of âge, entered the La Charité, during the month of 
October, 1820, in a state of emaciation, the organic cause of which could wïth dif- 
ficulté be appreciated. No cough ; no dyspnœa ; dull sound under the left 
clavicle on percussion ; respiratory mur mur more obscure there than in any cther 
part ; no sweat ; puise habitually a little fréquent ; tongue pale and moist ; appe- 
tite gone. For three weeks we saw this woman waste away more and more every 
day ; at the end of this time she was suddenly seized with attacks of vertigo, 
which were succeeded by loss of consciousness after two hours. At the morning 
visit her intellectual and sensorial faculties appeared entirely suspended ; the 
limbs, when raised, fell by their own weight ; those of the -left side insensible to 
pinching ; the right not so much so ; respiration stertorous ; puise hard, but free 
from frequency. Death the same day towards evening. 

Post mortem — Cranium. — Veins ramifying over the net-work of the pia mater 
covering the cérébral circumvolutions were very much dilated at intervais ; 
thèse were genuine varices, Their parietes, soft and friable, were torn and 
reduced to a kind of pulp by the least force. A layer of coagulated blood, at 
least six lines in thickness, covered the entire upper surface of the right hémi- 
sphère. After subjecting thèse parts to a stream of water, it was ascertained that 
one of the large varicose veins, which traversed the pia mater on the right, was 
perforated ; it presented a large orifice with irregular-jagged edges, which was in 
some measure stopped by a small clot of blood. On the posterior lobe of the 
same right hémisphère, there were remarked four circumvolutions, which, at their 
surface, were changed into a bright red, areolated, fungous-like tissue, in the midst 
of which appeared three or four small cavities, each of which might admit a pea, 
and were filled with blood. In thèse parts the cérébral pulp presented not the 
least softening. 

Thorax. — The summit of the right lung presented a portion, the size of an egg, 
black as ink, and changed into a liquid putrid substance, which exhaled an infec- 
tious odour. No communication as yet seemed to be established between this 
part, which was evidently gangrenous, and the bronchi. 

Remarks. — This is another instance of lésion of the encephalon liraited to the 
circumvolutions ; but their change differs in several respects from that presented 
in the first case. This altération partly existed for a very long time before any 
cérébral symptom developed itself. The dilatation of the veins of the pia mater, 
and the softening of their walls, were certainly the effects of chronic disease. That 
remarkable development of the substance resembling erectile tissue, on the surface 
of some circumvolutions, was also a chronic affection. The production of this 
tissue depended, in ail probability, on the dilatation of the capillary veins of the 
cérébral pulp, which were thus affected with the same kind of lésion as the external 
veins in which they terminate. But what is very extraordinary, ail this morbid 
process went on without any appréciable disturbance of the cérébral functions 
resulting from it. Then a period arrived, when there was a simultaneous lacéra- 
tion of one of the large external veins, and several of the small veins, the dilatation 
of which gave to some cérébral circumvolutions the appearance of erectile tissue. 
Thence resulted a double effusion of blood, the one being in the pia mater, the 
other in the pulp of the circumvolutions ; and then only was it that the cérébral 
symptoms appeared. Violent vertigo was succeeded by a complète abolition of 
the sensés and of intelligence ; then coma supervened, in which the patient died. 
The loss of motion on one side of the body, and its préservation in the other, 
showed that only one hémisphère was the seat of lésion, which is contrary to what 



96 



CLINIQUE MEDICALE. 



occurred in the first case. We may remark here that there was no symptom 
from which we could have suspected the gangrené of the lung observed in this 
case. 

Case 3. — Effusion ofblood into the anterior lobe ofthe left hémisphère qf the brain — 
Hemiplegia on the right side — Remarkable embarrassment qf speech — Death on 
the ninth day. 

A labourer, fifty-seven years of âge, entered the La Charité in the following 
state : — Intelligence very dull ; extrême difficulty in pronouncing his words ; he 
commences several phrases without being able to finish any ; after articulating 
with great difficulty some few words, there is nothing afterwards heard but an 
unmeaning stammering ; when he is spoken to for any time, he laughs and cries 
alternately. He can give no account of what happened to him. Face red ; 
eyes injected ; left commissure of lips drawn up ; this side of the face alone 
îs moveable ; still he complains equally whether the left or the right side of the 
face be pinched ; cannot by any effort put out his tongue ; the two extremities of 
the left side are moved with ease, whilst those of the right side are deprived of ail 
voluntary motion ; the cutaneous sensibilily does not appear to be diminished 
there. We find that four days previously this person fell down in the street 
deprived of consciousness, about eleven o'clock in the morning ; that when brought 
home he did not recover it till the following day, and that since he has con- 
tinued in the state described. During the four days following the tongue became 
dry and black, urine passed involuntarily, puise fréquent, extremities cold, respira- 
tion embarrassed, and he died nine days after the attack of apoplexy. 

Post mortem. Cranium. — The portion of cérébral substance which terminâtes 
anteriorly the left hémisphère, is marked by a cavity which might contain a 
pullet's egg, and which is filled by a large clot of blood. This cavity commences 
an inch below the upper surface of the hémisphère, and half an inch from its 
anterior extremity ; posteriorly and inferiorly it is bounded by the portion of 
cérébral substance which forms the point of junction of the superior and anterior 
walls of the left latéral ventricle. Both this latter and the corpus striatum are 
perfectly intact. The parietes of the accidentai cavity présent on their internai 
surface a bright yellow colour, which is continued two or three lines in depth. 
The cérébral substance no where softened. No other appréciable lésion in the brain. 

Thorax. — Lungs infarcted, and hepatised also in several parts ; heart large ; 
hypertrophy of the left ventricle. 

Abdomen. — Red softening of the gastric mucous membrane in its left half ; 
slate-coloured tint of the pyloric portion. Numerous arborisations in the small 
intestine. Spleen large and very soft. 

Remarks. — This case has been cited as an instance of hemorrhage exactly 
limited to one of the anterior lobules of the hémisphères. According to the 
theory which attributes the direction of the movements of the lower extremities 
to the anterior part of the cérébral hémisphères, we should only have found here 
paralysis confined to the lower extremity of the right side, and yet the upper 
extremity of the right side was equaïly deprived of motion. The paralysis 
extended also to the right side of the face, and the motions of the tongue could 
no longer be performed. The articulation of the words was become very 
difficult, a circumstance which is found in accordance with the opinion put forth 
by Dr. Bouillaud with respect to the encephalic seat of speech. We content 
ourselves with noting here thèse différent facts, proposing to ourselves, in our 
recapitulation, to add them to others for the purpose of resolving the important 
questions to which we have just referred. At the same time that the power of 
motion was abolished in one side of the body, sensibility was preserved intact on 
that side. With respect to intelligence, it w r as singularly dull ; memory seemed 
gone altogether. The commencement had been marked by a sudden loss of 



DISEASES OF THE ENCPHALON. 



97 



consciousness, and here again there was a coïncidence betvveen a cérébral 
hemorrhage and a hypertrophy of the heart. It was not in conséquence of this 
hemorrhage that the patient died. The perfectly sound state of the brain around 
the apoplectic clot was a good condition for the absorption of the effused blood. 
Death was the resuit of a double inflammation of the lungs and stomach, which 
particularly evinced itself by the adynamic state into which the patient sô 
suddenly fell. Such a mode of death is extremely rare in apoplectic subjects. 

Case 4. — Effusion of blood into the posterior lobe of the left hémisphère — Sudden loss 
of speech and motion on ail the right side — Death the sixth day. 

A house painter, fifty-five years old, who appeared to be of a strong constitu- 
tion, was brought to the La Charité, the 7th August, 1820, in a state of complète 
hemiplegia of the right side. He had had lead colic several times, and still felt 
acute abdominal pains, when on the ôth of August he was suddenly deprived of 
speech, and of motion on the right side. On the 7th he presented to us the fol- 
lowing state : — Lies on his back ; the eye-lids of the right side, which were glued 
together, open less wide than those of the opposite side ; the two eyes seem to 
be equally sensible to the impression of light ; the left buccal commissure is 
drawn upwards and outvvards ; the tongue on being protruded déviâtes to the 
right ; the upper and lower extremities of the right side are deprived of ail 
motion ; they may be flexed or extended without any résistance being opposed to 
them. (Bled to sixteen ounces, two blisters to legs, purgative lavement.) The 
blood drawn from the vein was buffed. He was bled again on the next day, &c, 
and on the day after he was in a constant stupor ; respiration loud ; involuntary 
discharge of urine ; obstinate constipation. He remained in this state till the 
24th, when the sensibility of the paralysed limbs became very much diminished : 
purgative lavements, &c, were prescribed. On the 2-ith, for the first time, 
diarrhœa came on ; tongue dry. From 24th to SOth, constant purging ; patient 
is becoming debilitated ; intelligence intact ; he makes an effort to answer when 
interrogated, but cannot articulate a word. The abolition of speech continued 
from the time of his entering the hospital. The 31st of August, extrême prostra- 
tion ; groaning ; rétroversion of the head ; left commissure of the lips drawn very 
much upwards ; tongue always dry, and inclined to the right ; upper eye-lid of 
the right side always more depressed than the left ; puise small and weak ; 
extremities cold ; respiration more and more difficult and stertorous ; death. 

Post mortem twenty hours after death. 

Cranium. — Vessels of the pia mater very much gorged with blood. No sérum 
in the external arachnoid, nor in the ventricles. In the substance of the posterior 
lobe of the left hémisphère, behind and outside the optic thalamus, which con- 
tinued intact, and nearly on the same level with it, we observed a cavity large 
enough to contain a small apple, which was filled with blood of the colour of iron 
rust, partly liquid, and partly coagulated. A very fine cellular membrane lined 
the parietes of this cavity. The cérébral substance around it was of a dirty rose 
tint, and was a little softened for the extent of some lines. 

Tîiorax. — Lungs infarcted, sound in other respects j heart large ; hypertrophy 
of the parietes of the left ventricle. 

Abdomen. — Some red dots on the inner surface of the stomach, towards the 
great cul de sac. In several places bright red injection of the mucous membrane 
of the small intestine, and of that of the large intestine, the redness of which is 
found to increase as we approach the rectum. 

Remaries. — This case differs particularly from the preceding with respect to the 
seat of the effusion. Here it existed in the posterior part of one of the hémi- 
sphères, in that part which, according to some authors, régulâtes the motions of 
the upper extremities : in this case, however, the lower extremity w r as paralysed 
as well as the upper. The loss of speech continued from the commencement to 

H 



93 



CLINIQUE MEDICALE. 



the end of the disease ; this was even the first symptom, and yet no lésion was 
found in the anterior part of the hémisphères. If then the third case, which also 
exhibited loss of speech, seems to confirm the opinion which places this faculty in 
the anterior lobes of the hémisphères, the présent case completely upsets this 
opinion. We shall remark, besides, that at the commencement the intelligence 
was not disturbed, and that it was not till a considérable time after the attack that 
stupor supervened. Here again an intestinal inflammation complicated the 
cérébral affection, and hastened the patient's death, which did not take place till 
the 26th day ; we also found on the walls of the hemorrhagic cavity a pseudo- 
membrane, which was already organised into cellular tissue. There was further, 
in this case, around the cavity, a little rose-coloured softening, the existence of 
which was not indicated by any particular symptom. 

Case 5. — Effusion ofblood into the posterior lobe ofthe left hémisphère— Par aly sis oj 
the upper extremity of the right side ; préservation of sensation and motion in the 
corresponding lower extremity — Death on the 20th day. 

A carpenter, twenty-nine years old, entered the La Charité, 29th June, 1829. 
We ascertained that, nineteen days previously, he had ail at once lost conscious- 
ness ; that at the end of twenty hours he commenced to recover the use of his 
intellects. The following days he remained paralysed in the right arm. He was 
bled twice. The day before entering the hospital, he relapsed into coma. 

On the 29th, we found him in a profound stupor ; not a word could be elicited 
from him ; eyes shut ; cheeks a violet tint colour. The right upper extremity 
extended along the trunk, when raised, fell again as an inert mass. The skin of 
this extremity was insensible to pinching. On the contrary, when we pressed the 
nails into the skin of the left upper extremity, this limb w r as quickly drawn back, 
the muscles of the face became contracted, and the patient moaned. We then 
pinched gently the lower extremities, which were immoveable and extended, and 
the patient did not seem to feel it. On pinching them more severely, the two 
lower extremities quickly performed some rapid movements ; we saw them, on the 
right as well as on the left, carried alternately in différent directions ; at the same 
time he uttered some groans. It thus became évident that sensation and motion 
were lost only in the right upper extremity, and that both thèse faculties were 
particularly retained in the corresponding lower extremity. Puise hard and 
fréquent ; respiration hurried. The patient died on the 30th June. 

Post mortem. Cranium. — Some lines below the circumvolutions belonging to the 
posterior lobe of the left hémisphère, two inehes anterior to the point where this 
lobe touches the occipital, it was marked by a cavity capable of containing an 
ordinary sized nut, and was filled with a blackish brown clot of blood. At the 
bottom of one of the anfractuosities situated above the effusion, was observed a 
cleft, through which the anfractuosity communicated with the apoplectic cavity ; 
some liquid blood traversed this cleft, and had raised the pia mater which lined 
the anfractuosity. The parietes of the cavity, containing the clot ofblood, were 
of a bright r.ed, and around it, for the extent of two or three lines only, the cérébral 
pulp had lost its usual consistence. The large arteries at the base of the brain 
presented numerous cartilaginous or bony patches. 

TJiorax. — Lungs infarcted ; heart very large ; hypertrophy of the parietes of the 
two ventricles, with dilatation of the cavity of the left ventricle. Some ossifica- 
tions at the aortic valves, as well as in the aorta itself. 

Remarks. — Here again is a case where the sanguineous effusion was exactly 
limited to the posterior part of one of the hémisphères : it is but inconsiderable, 
and nearly touches the circumvolutions : it présents this remarkable circumstance 
of a communication between the apoplectic cavity and the exterior, by means of 
the rent at the bottom of an anfractuosity. Here the upper extremity opposite to 
the side of the hemorrhage was the onjy one affected ; the corresponding lower 



DISEASES OF THE ENCEPHALON. 



99 



extremity remained intact ; so that this particular case is confirmât) ve of tne 
opinion which places the seat of the motions of the upper extremities in the pos- 
terior part of the hémisphères ; but \ve must not forget that the fourth case gave 
us quite an opposite resuit. The patient was perceptibly getting better, when, 
three days before his death, he relapsed into that state of coma which had existed 
at the outset of his affection. Did this relapse coincide with the time when the 
blood strove to make its way so as to cover the external surface of the brain, by 
escaping through the rent made in a point of the walls of the apoplectic cavity ? 
The death did not take place till the 20th day ; there was, as yet, no appearance 
of the formation of a false membrane on the walls of the cavity containing the 
blood. We have seen that it was already very weli formed in the patient who 
forms the subject of the 4th case, who died on the 26th day. 
In this patient, again, there was aneurism of the heart. 

Case 6. — The subject of this case was a woman, fifty-five years of âge, who 
appeared to have been originally of a strong constitution. From the period at 
which she ceased to menstruate, namely, at the âge of forty-seven, she became 
very fat, and was troubled with constant giddiness of the head. Four years after 
she had a slight apoplectic attack, which went off after a few days. After four 
years more she had another attack, with entire loss of consciousness, for which 
she was blistered, &c. After about a week, she was removed to the La Charité ; 
when she presented the folio vring state : — Countenance fiushed ; paralysis of the 
upper eye-lid of the right side, with déviation of the globe of the eye outwards ; 
unable to protrude the tongue ; hearing obtuse ; loss of voice and of speech ; the 
patient, who seems quite dull, hears, however, what is said to her, but cannot 
answer, except by making signs with her head. Motion in the two extremities of 
the right side destroyed ; fœces and urine passed involuntarily ; puise hard, and 
free from frequency ; leeches were several times applied across the jugular veins, 
and purgative lavements administered. On the 19th, she appeared to be getting 
better in every respect, except as to speech ; but, on the 25th, she relapsed into 
coma, respiration became more and more difïicult, and she died on the 27 th. 

Post mortem. Cranium. — In the substance of the middle lobe of the left hémi- 
sphère, external to, and a little above the point of junction of the optic thalamus and 
corpus striatum, was found a collection of blood (about six ounces), of which one 
part was liquid, and the other coagulated. A fibrinous layer, not organised, 
covered the inner surface of the walls of the cavity containing this blood. For the 
space of two or three lines around it, the cérébral pulp was a little softened. 

Thorax. — Lungs generally infarcted, hepatised in several points. Heart large ; 
remarkable hypertrophy of the walls of the left ventricle. 

Abdomen .— Mucous membrane of the stomach presented a greyish tint. Liver 
very large, greasing the scalpel. 

Remarks. — The seat of the hemorrhage is here in the very centre of one of the 
hémisphères, and there is hemiplegia. Theory might have anticipated this ; but 
the circumvolutions were not at ail engaged, and yet the intelligence was not 
intact. No altération in the anterior lobe, and yet there was complète ioss of 
speech. Here then we have in succession three facts (cases 4, 5, and 6), in which 
the lésion résides once in the anterior lobe, another time in the posterior lobe, and 
once in the middle lobe, and in thèse three cases there was equally loss of speech. 
In this case the dizziness for a long time preceded the apoplectic attack of which 
she died. We did not find in the brain any trace of that which she had had foui 
years before. Perhaps she was then attacked merely with simple cérébral con- 
gestion, sufnciently severe to produce the symptoms of hemorrhage, of which we 
have already seen instances. Neither will the state of the brain account for the 
return of the coma two.days before death. 

h 2 



100 



CLINIQUE MÉDICALE. 



Case 7. — Effusion of bïood into the middle part of the right hémisphère. Some 
softening of the cérébral substance around this effusion. Death on the seventh 
month. 

A periwig maker, seventy-one years of âge, of a good constitution, fell suddenly, 
deprived of consciousness, on the I5th of May, 1820. This loss of consciousness 
lasted but for some hours. When he came to himself, he found that he was para- 
lysed in ail the left side of the body. He entered the La Charité June 28, and 
presented the following state : — Pain towards the summitof the head, particularly 
on the right side : sight and hearing weaker on the left than on the right ; left 
buccal commissure immoveable ; the right drawn out ; tongue inclined to the left 
side ; complète loss of motion in the upper and lower extremities of the left side ; 
sensibility of thèse same members very much impaired, but not quite extinct ; 
obstinate constipation ; puise full, a little fréquent ; intellect perfect. On the 4th 
of July it was observed that the left side of the thoracic parietes was covered with 
an enormous anthrax. A crucial incision was made into it to a considérable 
depth ; whitish eschars were detached from it by degrees ; towards the end of 
August. it was scarcely cicatrised. During the month of September another 
anthrax, still larger than the former, appeared in the supra-spinous fossa of the left 
scapula. Other smaller ones appeared m succession in the vicinity of this latter 
one, always on the left. At this time the paralysed limb became atrophied, and 
permanently contracted, the fore-arm on the arm, and the leg on the thigh. He 
complained when we attempted to move his limbs. He passed his urine and fœces 
involuntarily. Towards the month of October he became very feeble ; scarcely 
ever spoke ; large eschars formed on the sacrum ; the contraction of the left upper 
extremity ceased, whilst its immobility remained. He died the 21st of November 
without his respiration having become stertorous. 

Post mortem. Complète marasmus, extremities rigid, broad uîcers on sacrum 
and trochanters, 

Cranium. — Its walls very brittle ; dura mater strongly adhèrent to the vault of 
the cranium ; arachnoid of the convexity a little opaque ; right hémisphère of 
brain presented a cavity capable of containing a middle-sized appîe. This cavity at 
an equal distance from the two extremities of the hémisphères, near the circumvolu- 
tions of the upper surface, external, superior, and posterior to the corpus striatum. 
Its parietes were lined by a cellular membrane, dense, very resisting, in the tissue 
of which numerous vessels were ramifîed. By its inner surface, this membrane 
adhered closely to the cérébral substance which is removed along with it. The 
cavity is filled with a softish substance having the colour of iron rust. The sur- 
rounding cérébral substance is softened to the extent of four or five lines. The 
softened portion has a slightly yellow tinge. Some little sérum in the ventricles 
and at the base. 

Remaries.— We have met a symptom here which did not présent itself in any of 
the preceding cases, namely, the flexion with which the paralysed limbs were 
afFected at a certain period of the disease. The lésions found in the brain do not 
sufficiently account for it ; for the softening in this case was not greater than in 
the preceding. The atrophy of the paralysed limbs may be referred to the long 
duration of the paralysis. We see here, as in the other cases, paralysis of the 
face, that of the organs of the sensés, existing on the same side as paralysis oi the 
limbs, and the tongue deviating, when protruded, towards the paralysed side. 
Still amidst thèse disturbances of sensation and motion, the intelligence remained 
intact ; the speech was not affected. The lésion, however, was similar in its seat 
and nature to those in the above-mentioned cases, where the intelligence was 
disturbed and the speech entirely lost. What difficulties ! AfFecting not to see 
them, certainly is not resolving them. This is the first time we met so perfectly 
organised a membrane around the effused blood, which may be referred to the 
long duration of the disease. 



DISEASES OF THE ENCEPHALON. 



101 



Case 8. — Cavity filled with a serons liquid in the middle part ofthe right hémisphère. 
—Two years before death, symptoms qf cérébral hemorrhage. — Hypertrophy of the 
heart — Pulmonary apoplexy. 

A man,sixty-one years of âge, experienced, from his youth, some oppression when- 
ever he exerted himself ; the effort to ascend a staircase brought on insupportable 
beating of the heart. He had met, at différent times of his life, distressing annoy- 
ances which made a great impression on him, and visibly aggravated his state. In 
the month of February, 1820, he felt for the first time very intense headachs, and 
dizziness so severe that it obliged him to discontinue his business. Four days 
after experiencing thèse symptoms, he suddenly fell deprived of consciousness. 
He was immediateîy bled from the foot, and in about a quarter of an hour his 
intellectual and sensorial faculties returned ; but the left upper extremity was 
weaker than the right; the patient felt it heavy. He sustained himself equally 
well on his two legs. This partial paralysis lasted from fifteen days to three 
weeks, then disappeared entirely. But from that period he retained the headachs 
and fréquent dizziness, which often compelled him to sit down lest he should 
fall. Dating from the month of September, 1821, the dyspnœa, as also the palpi- 
tations, became more and more violent, and the dizziness became more fréquent. 
The patient was now unable to attend to his ordinary business. He was bled 
repeatedly, both locally and generally. He wasted away very much, still retain- 
ing some appetite. On the 21st of January, 1822, after his dinner, syncope came 
on him which lasted for some minutes. During the night he laboured under 
extrême difficulty of breathing, and had very distressing kinks of cough. On the 
following day his legs appeared infiltrated for the first time. He entered the La 
Charité on the 26th of January ; and at the visit on the 27th he presented the 
following state : — Orthopnœa ; face puffed ; lips had a violet appearance ; œdema of 
the legs and hands ; cough fréquent and dry ; beating of the heart very violent, 
the impulse being very strong in the praecordial région, and extended over a con- 
sidérable surface ; puise fréquent, small and irregular ; tongue natural ; reluctance 
to take food, for fear of augmenting the oppression. Up to the 31st ail the symp- 
toms became aggravated, and on the 31st he expectorated about three ounces of 
blood mixed with aërated mucus. On the lst of February prostration became 
very great ; respiration blended with a râle ; cough dry ; fœces passed involun- 
tarily ; puise extremely weak. Died on the morning of the 2nd. 

Post mortem eight hours after death. Crarawwz.— Dura mater adhering superiorly 
to the parietes of the cranium ; sub-arachnoid cellular tissue infiltrated with a 
gelatinous and transparent liquid. On cutting from above downwards, and layer 
by layer, the substance of the cérébral hémisphères, we find in the right hémi- 
sphère a cavity with its parietes nearly contiguous, containing some drops of 
sérum, situate in the centre of the middle lobe, a little above and outside the latéral 
ventricle. This cavity extended two inches from before backwards, and one inch 
vertically. Around it, for the space of two or three lines, the cérébral substance, 
of natural consistence, is of a yellowish tint. Its parietes were lined by a smooth, 
consistent membrane, about a quarter of a line thick, similar to a serous membrane. 

Thorax. — Heart very large ; considérable hypertrophy of the walls of the left 
ventricle ; dilatation of its cavity ; cartilaginous points on the valves surrounding 
the orifice of the aortic ventricle ; right cavities distended with large clots of 
blood, deprived of colouring matter. In the centre of the lower lobe of the right 
lung, we find a portion of the pulmonary tissue of the size of an orange, black, 
hard, not floating in water, and from which there is expressed a deep brown liquid. 
The same lobe contains several other similar masses, but smaller. Some were 
also found at the base of the left lung. Thèse two lungs are, moreover, very 
much infarcted in every part. 

Abdomen. — The gastric mucous membrane presented a slate-coloured tint j con- 



102 



CLINIQUE MEDICALE. 



siderable venous injection in the parietes of the small intestine ; red tint on the 
free edge of its valves ; a brown red mucus on its interior ; liver gorged with 
blood. 

Remarks. — The apoplectic symptoms experienced by this person, two years 
before his death, raight have depended on simple cérébral congestion carried to a 
high degree. There was, however, then, in the substance of the brain, a hemor- 
rhage, not considérable no doubt, the existence of which was proved by the cavitv 
found in the right hémisphère ; the loss of consciousness was of but short duration, 
and the partial paralysis which succeeded it, also soon disappeared. Remark 
here the intensity of the dizziness preceding and following the hemorrhage. In 
this case, again, there was a coïncidence between the latter, and the existence of 
an old affection of the heart ; and does it not appear that it is to this affection we 
must attribute, at least as a predisposing cause, the double hemorrhage which 
attacked alternately the brain and lung ? 

Case 9. — Effusion of blood into the corpus striatum of the right side — Sudden loss of 
consciousness — Hemiplegia on the left — Death the fifteenih day. 
A woman, forty-eight years old, addicted to wine, fell, suddenly deprived of 
consciousness, the 16th of March, 1823. A little time after she was bled ; at the 
end of two hours she came to herself. She entered the La Charité the same 
evenîng. On the next morning, we found the two extremities of the left side 
completely deprived of motion and sensation. The right commissure of the lips 
was drawn upwards ; intellects perfect ; puise hard, vibrating, a little fréquent 
(she had blisters to the legs, and purgatives). On the following day, a visible 
amendment ; sensibility restored in the paralysed side ; the left lower extremity 
begins to perform some movements ; the left upper extremity as much paralysed 
as on the preceding day. The 1 9th, she moves the leg and thigh of the left side 
with ease ; puise not fréquent (a blister between the shoulders). From this period 
to Ist April, symptoms of gastro-intestinal irritation manifested themselves ; 
tongue red and dry ; great thirst ; tension of the abdomen ; diarrhœa ; delirium 
soon came on ; the patient died in what is called the adynamic state. The para- 
lysis of the lower extremity of the left side had been completely removed, not so 
of the upper. 

Post mortem. Cranium. — The only lésion presented by the encephalon was in 
the right corpus striatum. Towards the middle part of this substance, some liues 
beneath its upper surface, was found a small cavity filled with clots of blood. 
Around them the cérébral pulp was very soft for the space of three or four lines. 

Thorax. — Hypertrophy of the walls of the left ventricle of the heart, with con- 
traction of its cavity. 

Abdomen— Gastric mucous membrane very soft and red through the entire 
splenic portion. Intense redness, and, as it were, granular appearance of the 
inner surface of the ilium through a great portion of its extent. 

Remarhs. — It is rare to find hemorrhage so exactly limited to the corpus striatum 
as in the above case. The commencement of the affection was similar to that of 
the generality of cérébral hemorrhages, whatever be their seat. The sanguineous 
effusion being inconsiderable, the patient soon recovers the use of lier sensés, and 
her intelligence continued quite perfect, which, in this case, may be referred to 
the seat of the hemorrhage having taken place far from the substance of the cir- 
cumvolutions. At first, the two extremities of the side opposite to that of the 
sanguineous effusion were equally paralysed, which already invalidâtes the opinion 
according to which isolated lésions of the corpus striatum should modify motion 
only in the inferior extremity. But this is not ail : one of the paralysed limbs 
soon recovers the power of moving, and that is the lower extremity — that is to 
say, that limb which, according to the opinion just now mentioned, should alone 
have continued deprived of motion. Thus, the more we advance, the more will 



DISEASES OF THE ENCEPHALON. 



103 



ihese facts corne to destroy, or at least to stagger assertions too hastily made. 
There was no appearance in this case of any curative process having been set up 
around the hemorrhagic cavity. The most alarming cérébral symptoms had, how- 
ever, ceased, and it was under a complication of gastro-intestinal inflammation that 
she sank. She, too, had hypertrophy of the heart. 

Case 10. — Traces of an old effusion of blood into the right corpus striatum — Hemi- 
plegia, preceded by loss of consciousness — Death thirteen months after the attack 
of apoplexy. 

A hair-dresser, forty-six years of âge, entered the La Charité the 27th of 
January, 1822. He told us that, on the 21st of February, 1821, he had had an 
attack of apoplexy, during which, he told us, he had entirely lost ail consciousness. 
On coming to himself, he was paralysed in the two extremities of the left side. 
By degrees this paralysis diminished, and when we saw him, he merely felt some 
debiîity in the left extremities. The arm of this side appeared to him not so strong 
as the other, and in walking he dragged the leg a little. He also presented ail 
the signs of pulmonary phthisis, of which he died the 1 lth of April, 1822. 

Post mortem. In the posterior part of the right corpus striatum, nearer its 
external than its internai part, about an inch and half below its upper surface, a 
cavity was found an inch in length, and an inch and a half in breadth. It was filled 
with a substance, similar in colour and consistence to a concentrated décoction of 
chocolaté. No false membrane extended over the parietes of this cavity. Around 
it, for the extent of about half an inch, the substance of the corpus striatum was 
transformed into a yellowish pulp. Caverns and tubercles in the lungs ; heart 
normal ; ulcérations in the intestines. 

Remarks. — Here again the lésion was confined to the corpus striatum, and stiîl 
there is hemiplegia. Observe, however, that it was in the posterior part of the 
corpus striatum that the hemorrhage took place. The paralysis, though consider- 
ably diminished, existed, however, in a slight degree at the time of death. We 
saw what was the state of the corpus striatum, after the lapse of more than a year 
since the hemorrhage. There was yet no organised membrane on the parietes of 
the cavity, and around it the cérébral substance had neither the natural consist- 
ence nor colour. Look again, on the contrary, to the 8th case, in which the 
apoplectic cavity and neighbouring parts, presented quite a différent appearance, 
and also ail the symptoms of cérébral hemorrhage had disappeared long before 
death. 

Case 11. — This was the case of a man sixty years of âge, who was admitted 
towards the commencement of November, into the Maison de Santé, with a disease 
of the heart of long standing. The two extremities of the left side were also 
paralysed ; intelligence perfect. About three weeks before his admission, he told 
us he felt his left leg fail under him, and he fell, not however deprived of consci- 
ousness. A little after he found the upper extremity of the left side also deprived 
of motion; the sensibility of the paralysed limbs remained. His dyspnœa increased, 
as also his dropsy,and he died on the 25th of November, the hemiplegia continuing 
to the last moment. 

Post mortem. In the centre of the right optic thalamus, there was found a 
cavity filled with black blood, of some consistence. The cavity was capable of 
containing a large cherry. 

Thorax. — Lungs infarcted ; hypertrophy of the parietes of the heart, and dila- 
tation of its cavities, which were filled with blood ; cartilaginous incrustation at 
the base of the mitral valve ; serous effusion into left pleura ; close adhésions 
between heart and pericardium. Two bony concrétions developed between this 
membrane and the proper substance of the heart. 



104 



CLINIQUE MÉDICALE. 



Abdomen. — Considérable injection of the intestinal raucous membrane in différent 
parts ; spleen very large, dense, and black ; liver gorged with blood. 

Remarks. — This case differs from ail the preceding, in this, that no loss of con- 
sciousness occurred when the hemorrhage came on. The two extremities of tbe 
left side were equally affected with paralysis, though the lésion existed but in one 
optic thalamus. 

Case 12. — Serons cysi in the left cérébral peduncle — Hemiplegia on the right side, of 
long standing, with diminution of the sensibilité — Death four years after the appear- 
ance of this hemiplegia. 

A woman, about sixty years of âge, entered the hospital La Pitié in the month 
of March, 1831, with the symptoms of a chronic peritonitis. She has been hémi- 
plégie for the last four years on the right side : the sensibility also on this side is 
impaired. She told us, that one morning on awaking, she found herself thus para- 
lysed, though she had gone to bed on the preceding night in perfect health. She 
states that neither since nor before this accident, had she either headachs, nor 
dizziness. She died fifteen days after her admission, without presenting any 
additional symptom connected with the brain. 

Post mortem. In the middle of the cérébral peduncle of the left side, we found 
a cavity capable of containing a cherry, filled with a greënish seium ; it was lined 
with a dense resisting membrane, the tissue of which seemed to be fibro-serous. 
Around it, to the extent of some Unes, the nervous substance was of a pearl white, 
and of cartilaginous hardness. Sero-purulent effusion into the right pleura, and 
also into the cavity of the peritoneum. Adhésions of the intestines by cellular 
bands which were still soft. 

Itemarhs. — We think that this woman was attacked four years before her death 
with hemorrhage, seated in the left cérébral peduncle. The lésion found in this 
peduncle seems to us to be formed according as the absorption of the effused 
biood goes on. After the latter disappeared, the paralysis stiïl remained, which is 
explained by the nature of the lésion found in the peduncle ; this is the first time 
we met an induration of the nervous tissue around an old hemorrhagic cavity. 
But observe, that this examination was made four years after the appearance of the 
first cérébral symptoms. Thèse symptoms were not very many, but well marked. 

Case 13. — Effusion of blood into a great fart of the substance of the right hémisphère 
— Destruction of the corpus striatum, and of the optic thalamus — Escape of blood 
into the right latéral ventricle — Death tivo hours after the appearance of the first 
symptoms. 

A man, thirty-seven years old, fell suddenly, deprived of consciousness, in one 
of the streets near the La Charité, to which he w r as instantly conveyed. When 
examined, he was found to be in a state of profound coma. The four extremities 
completely relaxed, and évince no sign of sensibility ; they are quite cold ; trachéal 
râle already ; puise fréquent (sinapisms to the lower extremities). An hour and a 
half after entering the hospital he died. 

Post mortem. On removing a few slices of the nervous substance from the right 
hémisphère, we came to an enormous effusion of blood, occupying- a great portion 
of this hémisphère. Instead of the nervous pulp, we fmd only half solid half 
Uquid blood, in which there are suspended some fragments of brain. The optre 
thalamus and corpus striatum no longer exist, and the right latéral ventricle is 
filîed with a large clot of blood. 

Remarks. — This case présents one of the most rapidly fatal cases of cérébral 
hemorrhage we have met on record. The severity of the symptoms is here 



DISEASES OF THE ENCEPHALON. 



105 



connected with the extent of the lésion ; a great portion of the right. hémisphère 
consisted of a vast cavity fuil of blood ; the corresponding ventricle vvas also filled 
with it. 

Case 14. — Effusion of blood into the middle of the right hémisphère--^ Other smaller 
effusions into the anterior and exterior parts of the same hémisphère — Svdden loss 
of consciousness — Hemiplegia on the left side — Death thefourth day. 
A baker, twenty-eight years of âge, entered the Maison de Santé, October 20, 
1830. He had worked hard for some time, and used to drink six or seven 
cups of café à l'eau every night. He enjoyed, however, good health. On the 
morning of the 19th October, he fell down suddenly, deprived of consciousness. 
He was bled. Afterwards he was conveyed to the Maison de Santé, where he 
presented the following state : — Complète loss of consciousness ; insensibility and 
loss of motion in ail the left half of the body ; strong pressure, made with the end 
of the finger, on the left transparent cornea, on the ocular and palpebral conjunc- 
tiva of this side, produces not the slightest movement either of the lids or the 
globe of the eye ; sight quite gone ; puise small, 100 ; respiration regular and 
calm (28 per minute). (A solution of sulphate of soda ; sinapisms to the feet, &c.) 
During the night ; sudden and rapid movements of the side not paralysed ; puise 
small, 120 ; skin covered with sweat. On the 21 st, some difficulty in svvallowing ; 
face more injected than on the preceding day. (Thirty leeches to the right side 
of the neck, sinapisms to the lower extremities, sulphate of soda in barley water.) 
Ail the symptoms continued to become worse, and he died on the morning of the 
2 th. 

Post mortem, forty-eight hours after death. Well marked sanguineous effusion 
of the sub-arachnoid cellular tissue of the convexity of the right hémisphère ; rose- 
tint of the subjacent grey substance ; large clot of blood in the centre of the right 
hémisphère, on a level with the centrum ovale of Vieussens, external to the corpus 
striatum and optic thalamus, wlr.ch are intact. An orange might be contained in 
the cavity occupied by this clot. Around the cavity, for the extent of four or five 
lines, the cérébral substance was softened, and marked with a great number of red 
points. In the anterior and posterior parts of the same hémisphère there were 
found several other small sanguineous effusions, with softening of the nervous 
substance around them. The cérébral pulp, where it is softened, présents an 
intensely red colour ; in some places it is merely dotted ; in other parts it is 
uniformly red, as if the cérébral substance had been steeped in red colouring 
matter. 

This case is remarkable for the number of the hemorrhages which took place 
simultaneously, or at short intervais from each other, in the right hémisphère of the 
brain.- Around each sanguineous effusion there was intense injection of the brain, 
with diminution of its consistence. Does not the hemorrhage here seem to be, as 
it were, the last degree of this lésion ? If this latter preceded the effusion, it was 
only by some seconds, as seems to be proved by the sudden manner in which the 
disease commenced. We have seldom seen so complète insensibility of the 
conjunctiva. In most of the cases wherein coma does exist, the eye-lids are still 
seen to approximate when the anterior surface of the globe of the eye is touched. 
The complète insensibility of this membrane coincided with a loss of sensation on 
the left side of the face. Such are several of the phenomena observed where the 
fifth pair of nerves are injured. We satisfied ourselves that this pair of nerves, in 
this case, was intact. 

Case 15. — Effusion of blood into the centre of each hémisphère — Sudden loss of 
consciousness — Resolution of the four extremities — Death the sixth day. 
A man, seventy-two years old, entered the La Charité, the 26th of February, 



106 



CLINIQUE MEDICALE. 



in the following state : — Profound coma ; gênerai insensibility of the skin ; reso- 
lution of the four extreraities, which fall again as inert masses, when left to them- 
selves, after being raised ; upper eye-lids half depressed over each eye ; no sign 
of vision ; slight winking when we attempt to touch the conjunctivse ; respiration 
râlante. We ascertained that, for some time back, this person had frequently 
fallen into a swoon. On the 2oth of February, at eleven o'ciock at night, he had 
had one longer than usual, and did not corne to himself again. This was ail we 
could learn. Nothing particular occurred tiîl his death, which took place on the 
4th of Mardi. 

Post mortera. Serous infiltration of the pia mater of the convexity of the 
hémisphères. At the union of the posterior third with the anterior two-thirds of 
the right hémisphère, only an inch below the upper surface of this hémisphère, 
and two inches from the point of junction of this upper surface with the inner 
surface, there was found a cavity, which might contain a nut, and which was filled 
with coagulated black blood. The nervous substance around it was natural. In the 
left hémisphère, nearly in the same place, there was found a cavity of the same 
diameter, equally filled with coagulated blood, without softening, or unusual 
injection around it. Lungs infarcted ; white patches on the external surface of the 
heart ; hypertrophy of the parietes of the left ventricle ; bony incrustation at the 
base of the mitral valve ; bony patches in the aorta. 

Remarks. — This case affords a striking example of the disagreement so often 
existing between the severity of the symptoms and the intensity of the lésions. 
The symptoms were those of very serious cérébral hemorrhage. We might have 
announced, by anaîogy with what is most usually observed, that a considérable 
portion of one of the hémisphères was the seat of a vast hemorrhagic cavity. 
Such was not the case, however. The effusion was very inconsiderable, but it 
was double ; and the close resemblance of the two effusions, their similar size, 
their situation in the same part of each hémisphère, the sound state of the cérébral 
substance around each, are not the least curious circumstances of this case. Was 
it because the hemorrhage was double, that, small as it was, it gave rise to such 
serious symptoms ? But we shall see, in the following case, a hemorrhage, also 
double, not followed by death, which took place from another cause, after the lapse 
of nine years. 

Case 16. — Serous cyst in each cérébral hémisphère — Old apoplectic attack — Death 
nine years after this attack. 

A woman, sixty-eight years of âge, stated to us, on her entering the hospital 
La Pitié, that, nine years before, she had had an attack of apoplexy, for which she 
kept her bed for at least two years, because during this time she said her limbs were 
very weak. She then began to get out of bed, and her limbs, by degrees, resumed 
their usual strength. When she came under our observation, she presented no 
trace of paralysis, and her intelligence was perfect. This woman laboured under 
a carcinomatous affection of the stomach, of which she died about a month after 
entering the hospital. 

Post mortem. About two inches below the upper surface of the right hémi- 
sphère, at the union of the anterior two-fifths with the posterior three-fifths of this 
hémisphère, not far from the point where its upper surface inclines, in order to 
become external, was found a small cyst, with smooth transparent parietes, filled 
with limpid sérum, without any change in the cérébral parenchyma around it. No 
change could be discovered in this hémisphère ; but in the opposite hémisphère, 
ou a level with, and external to the middle part of the corpus striatum, we found 
a second serous kyst precisely similar to the preceding. 

On the posterior surface of the stomach was found a cancerous ulcer. 

Remarks. — In this, as in the preceding case, blood was effused at the same time 



DISEASES OF THE ENCEPHALON. 



107 



into each cérébral hémisphère, the patient having assured us that she had had but 
one attack of apoplexy. But whilst, in the former case, death took place rapidly, 
in the latter, not only the termination was not fatal, but, at the end of some years, ail 
the symptoms wh'ich could announce the continuance of any altération in the brain 
were seen entirely to disappear. Thus, in this case, the cessation of the functional 
disturbances preceded by a long time the complète disappearance of the lésion 
\vhich caused them. 



SECOND SECTION. 

RECAPITULATION. 

In this résumé we propose to détail the différent functional disturbances to 
which cérébral hemorrhage gives rise, and to investigate how far the différences, 
which thèse disturbances présent, may be explained either by the extent of the 
effusion, or by the différence of its seat. 



CHAPTER I. 

LESIONS OF MOTION. 

The most characteristic symptom of cérébral hemorrhage is paralysis. We 
know of no instance of hemorrhage, however inconsiderable, taking place in the 
substance of the cérébral hemispheres,which was not accompanied by a diminution, 
more or less complète, more or less extensive, and more or less permanent, of the 
power of motion. In the cases above cited it may have been seen, that a very 
slight effusion was sufficient to produce paralysis ; that in gênerai its intensity was 
in the direct ratio of the extent of the effusion ; that it took place no matter what 
parts of the cérébral hémisphères were the seat of the lésion, and that, in fine, the 
différences with respect to the seat of the hemorrhage had very little influence in 
determining what parts of the body were attacked with paralysis. 

The paralysis developes itself at the very moment the effusion of blood takes 
place. It requires ail at once its highest degree of intensity, then remains 
stationary, or goes on diminishing. Sometimes the paralysed part had not 
previously experienced any disturbance with respect either to sensation or motion ; 
sometimes, on the contrary, the patients had experienced in thèse parts pricking 
sensations, numbness permanent or transient, an unusual feeling of cold, a sensé 
of weight, and a certain degree of debility. Thèse différent phenomena may 
announce two things : either the existence of a constant lésion, in the same point 
of the brain, where at a later period the hemorrhage shall take place, — as simple 
habituai sanguineous congestion, a softening which is still inconsiderable, some 
accidentai production ; or else the more or less fréquent return of a more serious 
congestion in the part of the brain where the blood is to be effused. 

The paralysis following cérébral hemorrhage présents great varieties with 
respect to its seat, and pathological anatomy is far indeed from being always able 
to assign the cause of such numerous varieties. 

This paralysis may be first distinguished into gênerai and partial. The first is, 
when the two sides of the body, whether in their entire extent, or in some of their 
parts, are at once deprived of motion, This gênerai paralysis we have observed 
in the three following cases : — 



108 



CLINIQUE MEDICALE. 



Ist. In the case of simultaneous or successive hemorrhage in the two 
hémisphères. 

2nd. In the case of considérable hemorrhage in only one hémisphère, with 
destruction of the parietes of the corresponding latéral ventricle, escape of blood 
into this ventricle, and from it into the other cérébral cavities, whether through 
the natural orifices of communication, or through the lacerated septum. 

3rd. In the case of hemorrhage in only one hémisphère, without effusion of 
blood into the ventricles, the hemorrhage being considérable enough to have 
broken down the greater portion of the substance of the hémisphère. 

In the case of gênerai paralysis the four extremities, when raised, fall again as 
inert masses, and this state always coïncides with loss of consciousness and profound 
coma. Sometimes it continues, and then the disease always terminâtes fatalh . 
Sometimes at the end of a short period it disappears, and nothing remains but 
hemiplegia. 

Again it may be remarked, that the existence of gênerai paralysis indicates 
cérébral hemorrhage with much less certainty than paralysis of only one haif the 
body. It is found accordingly in several brain affections widely differing from 
each other. 

Partial paralysis, which has corne on suddenly, is, on the contrary, one of the 
surest signs of hemorrhage in the cérébral hémisphères. This partial paralysis, 
which is much more common than the preceding, varies also very much with 
respect to the number of the parts affected. Whatever thèse parts be, it may be 
laid down as a law, that the paralysis affects the side of the body opposite to the 
hémisphère wherein the effusion of blood has taken place. The cases in which 
the contrary has been observed, are so few in number, that they can be considérée! 
but as very rare exceptions to the lawjust mentioned, which exceptions again have 
not yet been accounted for. Nor is it easier to say why hemorrhage in one 
hémisphère produces paralysis in the opposite side of the body. An attempt has 
been made to explain the phenomenon by the interlacir.g of the fibres of the 
upper part of the spinal cord ; but in the fîrst place this explanation can only be 
available for paralysis of the extremities ; we cannot have recourse to it for that 
of other parts, as of the face, for instance, the paralysis of which, as well as that 
of the extremities, uniformly takes place on the side opposite that of the 
hemorrhage, whilst the nerves distributed to the muscles of the face arise above 
the crossing of the fibres of the cord. 

The paralysis most frequently observed after a hemorrhage of the cérébral hémi- 
sphères, is, that of the two extremities of the side opposite that where the effusion 
of blood has taken place*. The cases we have cited have shown that a very 
inconsiderable hemorrhage, which affects scarcely a square inch of the substance 
of the hémisphères, may give rise to this hemiplegia. They have also satisfied us 
that the hemiplegia is equally produced, whatever be the point of the hémisphères 
wherein the effusion has taken place. Thus we have met it in cases where the 
hemorrhage had not passed the surface of the circumvolutions, just as in those 
where it occurred in the very centre of either hémisphère. We have also witnessed 
the hemiplegia in cases of hemorrhage strictly limited to the anterior, middle, or 
posterior lobe of one hémisphère, to the optic thalami, the corpora striata, and 
even to the cérébral peduncles. 

When the two extremities are simultaneously affected with the paralysis, they 
may be so in an equal degree ; but this is a rare case ; it usually happens that the 
loss of motion is most complète in the upper extremity. Nothing is more common 
than to find this extremity wholly deprived of motion, whilst the leg and thigh of 
the same side are still capable of being moved at the will of the patient. Often 

* Dr. Bright, vol. ii. p. 306, gives a case of hemiplegia on tlie left side, with cérébral 
lésion on the same side. See also Morgagni, Let. I. Epist. ii, § 16. — Th. 



DÎSEASES OP THE ENCEPITALON. 



109 



too the leg performs considérable movements, when the patient is in bed ; only 
thèse motions are somewhat slower than those of the opposite side, and the indi- 
vidual hirnseif dues not pereeive that one of his lower extvemities is affeeted, until 
he begins to walk ; we may even observe that he drags one of the legs along, or 
that he supports himself on it rather unsteadily. 

The moment when the hemiplegia becomes established coincides in many cases 
with a total loss of consciousness, and then the fall may take place indifferently in 
any direction. But when this loss of consciousness does not take place, the 
patient feels the lower extremity, which has been just struck with paralysis, sud- 
denly withdrawn from under him, and he falls, as a mass, on the side of the hemi- 
plegia, whilst he préserves ail his consciousness. In most of the cases published 
on cérébral hemorrhage, sufficient care has not been taken to distinguish the cases 
where the fall is caused by the paralysis suddenly supervening from those where 
it coincides with loss of consciousness. 

Hemorrhage of the cérébral hémisphères may also produce paralysis of only a 
single extremity ; sometimes of the upper, and sometimes the lower. The sepa- 
rate paralysis of the former we have found to be more common than that of the 
latter. We remember the case of a man, fifty years of âge, who, having gOne to 
bed quite weil, was astonished on awaking at not being able to move his left arm, 
or to see with his right eye. This person has now for the last five months been 
paralysed in the upper extremity of the left side, and deprived of the sight of the 
right eye. In no other part is there the slightest trace of paralysis ; he feels 
neither headach nor dizziness ; his intelligence is perfectly unimpaired, and has 
not been disturbed for a single moment. 

Some cases have been recently published with the view of proving that para- 
lysis of the upper extremities dépends on a lésion confined to the optic thalami, 
or to the nervous mass situated on a level with and posterior to them, and that 
paralysis of the lower extremities dépends on a lésion of the corpora striara, or of 
the nervous mass situate on a level with and anterior to them. To détermine the 
accuracy of this opinion, we too have interrogated facts*. Now, taking those only 
in which the lésion was perfectly limited, we found seventy-five of them in which 
this lésion (hemorrhage or otherwise) was circumscribed with sufficient exactness 
to qualify them for solving the question now before us. 

Out of thèse seventy-five cases, we reckoned forty in which the two extremities 
of one side were paralysed at the same time. Of thèse forty, there were twenty- 
one in which the seat of the lésion was the anterior lobe or corpus striatum, and 
nineteen in which the lésion was seated in the posterior lobe or optic thalamus. 

Of thèse seventy-five cases there were twenty-three in which the paralysis was 
confined to the upper extremity, in eleven of which the seat of the lésion was the 
corpus striatum or anterior lobe, in ten the lésion was seated in the optic thalamus 
or posterior lobe, and in two the seat of the lésion was the middle lobe. 

Again, of thèse same seventy-five cases we found twelve others in which the 
paralysis was confined to the upper extremity, in ten of which the seat of the 
lésion was in the corpus striatum or anterior lobe, whilst in two the lésion was in 
the optic thalamus or posterior lobe. 

From thèse facts we are led to the conclusion, that in the présent state of 
science, we cannot yet assign in the brain a distinct seat to the motions of the 
upper and lower extremities. No doubt such distinct seat exists, since each of 
thèse extremities may be paralysed separately, but we do not yet know it. 

At the same time that the extremities of one side of the body are paralysed, 

* Serres and Foville assert that lésions of the corpus striatum and anterior parts of the 
brain are followed by paralysis of the lower extremities of the opposite side, and that lésions 
cf the optic thalamus, or posterior parts of the cerebrum, cause paralysis of the upper extre- 
mities. Some of the cases reported by Dr. Bright seem to countenance this opinion. — Tr. 



110 



CLINIQUE MÉDICALE. 



other parts also may be similarly affected, but in différent degrees. Thèse parts 
are most commonly the following : — 

The globes of the eyes, The neck. 

The eyelids. The larynx. 

The différent parts of the face. The pharynx and œsophagus. 

The lips. The bladder. 

The tongue. The rectum. 

Of thèse parts there are none where paralysis is as common as that of the 
extremities, nor does it develope itself with equal frequency in the other parts. 
Thus the différent parts of the face and the tongue are more frequently the seat 
of it than the other parts above mentioned. Let us trace, however, the paralysis 
in each of them. 

Paralysis of the muscles which move the eyes is denoted by the constant 
déviation of the latter in some one direction ; it is then that strabismus is most 
enerally observed : but this phenomenon itself is very rare, and it is scarcely 
ever noted in those numerous cases published on cérébral hemorrhage : we have 
ourselves met it but in a few cases. In order to its production, it is necessary 
that the muscles antagonising those which carry the eye downwards and inwards 
should be paralysed. 

The muscles constituting the parietes of the cheeks lose the power of contrac- 
tion much more frequently than the preceding in cases of hemorrhage of the 
cérébral hémisphères. The buccinator is the muscle whose paralysis is most 
perceptible. Every time the patient expires, one of the cheeks is observed to be 
distended passively, and also at the same time one half of the lips corresponding ; 
and when subsequently the patient wishes to masticate, the food introduced into 
the mouth, and placed on the side of the paralysed buccinator, can be no longer 
acted on by it, and collects between the cheek and the teeth until removed by 
mechanical force. 

In ail the cases observed by us, and in ail those published with sufficient détail, 
the paralysis of the buccinator muscle has taken place on the same side as that of 
the extremities. 

The passive distension of one of the cheeks we have generally found to take 
place only in very severe cases, and when there is at the same time loss of con- 
sciousness. 

The muscles which move the lips often retain ail their power of motion, so that 
their commissures présent no déviation whatever. But at other times thèse 
muscles are paralysed ; and in conséquence of their antagonism being destroyed, 
the commissure of the lips is drawn to the opposite side and outwards, and at the 
same time it inclines sometimes upwards and sometimes downwards. In the 
great majority of cases, the déviation of the commissure exists on the side opposite 
to the hemiplegia ; it is consequently on the same side as the paralysis of the 
limbs that the paralysis of the muscles takes place, by which the lips are moved. 
Oftentimes when there is no motion exercised, and as long as the mouth is shut, 
there appears no déviation, but this becomes perceptible when the patient speaks 
or smiles. 

The degree of déviation of the mouth is not always in the direct ratio of the 
degree of hemiplegia. We have seen it very marked in cases where the paralysis 
of the limbs was very slight, whilst we have found it absent where the hemiplegia 
was complète. 

The tongue, with respect to its movements, présents very différent states in 
individuals attacked with cérébral hemorrhage. In the first place, its movements, 
in many instances, remain perfectly free. Several persons, who, after having 
continued some minutes unable to move it, appear suddenly to reco'ver the free- 
dom of its motion : they protrude it abruptly out of the mouth, after a great 
effort : but there are some movements which they cannot give the tongue, until 



D1SEASES OF THE ENCEPHALON. 



lll 



after considérable intervais. In others, again, those movements are completely 
destroyed, and whatever efforts the patients may make, they cannot protrude the 
tongue frora the mouth. Articulation*, however, may be still possible ; some- 
times there is considérable stamraering, and at other times the patient is unable 
to articulate a word, and the tongue's motion is entirely destroyed. Others, 
again, are able to protrude the tongue from the mouth, but not in a straight direc- 
tion, its apex deviating perceptibly to the right or left. According to our expé- 
rience, whenever the apex of the tongue deviated, it was towards the paralysed 
side more frequently than the contrary ; the latter déviation, however, scil. 
towards the sound side, has also been observed. Nothing but mere hypothesis 
has hitherto been proposed to account for the several modifications in the motions 
of the tongue f. 

Paralysie of the muscles of the neck has been but rarely observed in cérébral 
hemorrhage. The head then inclines to the paralysed side, whilst the face 
inclines to the opposite side. 

Paralysis of the muscles of respiration has been observed only in very alarming 
cases. In a very few instances, complète and sudden aphonia has been observed 
to supervenej. 

Paralysis of the muscles of the neck has been but rarely observed in cérébral 
hemorrhage. The head then inclines to the paralysed side, at the same time that 
the face inclines to the opposite side. We have never observed this paralysis as 
a conséquence of sanguineous effusion in one of the cérébral hémisphères. 

Paralysis of the muscles of respiration has been observed only in the most 
serious cases, in those to which the name of apoplexia fulnùnans has been given. In 
very few cases, complète and suddenly supervening aphonia has been observed. 
It was attributed to paralysis of the internai muscles of the larynx. 

Paralysis of the muscular layer of the pharynx and œsophagus is observed only 
in the worst cases, and is usually a fatal symptom. Sometimes, however, it has 
been found to cease, the power of déglutition return, and the patient restored. 
In still rarer cases, the dysphagia has been one of the precursory phenomena of 
an attack of apoplexy. 

Paralysis of the bladder is far from being a common phenomenon in individuals 
examined a considérable time after they have been struck with cérébral hemorrhage. 
Most of the old apoplectic cases received into the hospitals, do not présent it. 
Very few also discharge the fseces involuntarily, and it is very doubtful whether the 
more or less obstinate constipation, experienced by several of them, dépends on 
paralysis of the rectum. We shall recur, at a subséquent period, to the cause of 
this phenomena, when speaking of the state of the primse vise in apoplectic 
patients. 

* The affection of the articulation may, as Dr. Bright says, loc. cit., arise from différent 
causes : it sometimes dépends almost entirely on paralysis of the muscles of the face ; in which 
case hy supporting the paralysed cheek with the hand, the indistinctness of the articulation is 
partiafly removed. In other cases, however, the defect lies in the muscles of the tongue and 
of the larynx, so that it is not possible to produce the sounds. In the latter cases, Dr. Bright 
has found the posterior part of the corpus striatum the seafc either of pressure or of lacération. 
— Ta. 

f That the apex of the tongue should deviate towards the paralytic side, may be inferred 
à priori by considering the muscular power which protrudes the tongue. This is accomplished 
by the posterior portion of the genio-glossus muscle, of which the fîxed point is at the chin, and 
the moveable point at the base of the tongue. "When this portion of the muscle acts, its two 
extremities are approximated, and the base of the tongue is thus drawn forwards towards the 
fixed attachment of the muscle. If this attachment be to the right of the médian line, the 
base of the tongue is brought forwards and to the right, and, consequently, its apex forwards 
and to the left. See Lallemand, Letter Ist, p. 23. — Tr. 

£ When aphonia précèdes or succeeds apoplexy, it is always to be considered an alarming 
symptom, as it shows that the internai cause which interrupts the nervous influence, is situated 
about the base of the brain, and, probably, in the medulla-oblongata, which is considered the 
part of the nervous System most indispensible to life. — Tr. 



H2 



CLINIQUE MEDICALE. 



Paralysis, which is really the result of cerebrai hemorrhage, once produced. 
présents the essential character of continuing, even when ail the other symptoms 
accompanying it have disappeared. When death supervenes at the end of some 
days, the paralysis terminâtes onîy with life ; when, on the contra^, death does 
not take place till several months or several years after the apoplectic attack, 
three cases may then présent themselves : — either the paralysis continues in ail 
its intensity till the death of the patient, or eise it diminishes progressively, 
without completely disappearing, or else, in fine, it disappears altogether. 

In the fîrst of thèse three cases, the paralysis sometimes continues simple, and 
no other lésion of motion is complicated with it ; sometimes it is accompanied, at 
the end of a shorter or longer period, with a certain degree of rigidity, and even 
of real contraction. In such cases, we usually find, on examining, after death, 
différent altérations around the seat of the hemorrhagic cyst, either more or less 
extensive softening, or considérable induration of the cérébral substance. 

Frequently also, in such cases, the paralysed limbs waste away perceptibly, 
which probably dépends on their continued loss of motion. 

In the second case just mentioned, there is a graduai diminution of the paralysis, 
but at the end of several years we still find traces of it, The limbs may, to be sure, 
be capable of executing several movements, but they possess not the activity of 
those of the opposite side ; they seem insensible to the patient, who raises them 
with difficulty ; the fingers remain habitually flexed, and the hand cannot grasp 
objects firmly ; the patients are able to walk, but they drag the limb a little. 

When, in such cases, the cérébral hémisphères are examined, there is found in one 
point of them, either a serous kyst, or an oblong whitish line, surrounded b}' a 
portion of parenchyma a little hardened. We saw one case where a second attack 
of apoplexy terminated the life of a patient, who, twenty-seven years before, had 
experienced the first attack. In the Unie between the attacks, this person felt 
merely a weakness of the two extremities of the left side ; he used them, but with 
less freedom than those of the opposite side. Towards the middle of the right 
optic thalamus, there was found a hard line of a dull white, being six lines 
in extent from before backwards. Around it, there was no altération of the nervous 
substance. There was a récent effusion of blood into another part of the brain. 

The third case mentioned is that where, at the end of a shorter or longer period 
the paralysis entirely disappears, either in ail the parts attacked with it, or in some 
only. The parts where it disappears first, are generaily the tongue, the lips, the 
face, and, lastly, the extremities. In almost ail cases the leg recovers its power of 
motion before the arm : and there are cases where the patients have attained the 
power of using both the lower extremities with equal facility, though one of the 
upper extremities was still weaker than the other. 

On examining the encephalon of persons in whom a paralysis which has existed 
for a long time has finally disappeared, it may happen that no perceptible altéra- 
tion is found in the nervous substance ; even the whitish line, the last vestige of 
the hemorrhage, bas ceased to exist. But at other times, we still discover in the 
hémisphères différent lésions, such as cysts of variable size ; and yet, a considér- 
able time before death, every species of paralysis had disappeared. Here then is 
one and the same state of the brain with which, according to the individuals, para- 
lysis may exist or not ; another proof that beyond the morbid states appréciable on 
the dead body, there are others quite as important which escape the researches of 
the anatomist, and which add their all-powerful influence to that of the former, in 
permitting or preventing the manifestation of the functional disturbance. 

We have already seen that in cases of paralysis of long standing, the limbs 
deprived a long time of motion become rigid, or présent in a more or less rnarked 
manner the phenomenon of permanent flexion. But this is not ail : in some cases, 
from the time succeeding the hemorrhage, spasmodic and convulsive motions 
appear at intervais in the paralysed limbs, and at the same time also the side of 



DISEASES OF THE ENCEPHALON. 



113 



the face deprived of motion is agitated by more or less violent contractions. It 
would seem then that in virtue of peculiarity of disposition, the efFused blood acts 
as a stimulant on the nervous tissue, which gives rise to irritation of the latter, and 
to the appearance of those phenomena which have been just mentioned. In cases 
of this kind, we have sometimes found after death no particular lésion around the 
efFused blood ; sometimes we have discovered around it either a bright red injec- 
tion of the nervous substance, or a perceptible diminution of its consistence, with 
a red colouring more or less marked ; so that here again we have the same func- 
tional disturbances, whether we find or do not fînd on the dead body altérations 
to explain them. We also meet, from time to time, cases of cérébral hemorrhage 
in which, at the same time that one side of the body is affected with paralysis, the 
other is agitated with convulsive movements. Under such circumstances there is 
anormal stimulation of the hémisphère opposite to that where the hemorrhage has 
taken place. The perceptible traces of this stimulation are found sometimes in 
the nervous substance itself, which is injected or softened, sometimes in the mem- 
branes, which are red, thickened, infiltrated with pus, &c. 



CHAPTER IL 

LESIONS OF SENSIBILITY. 

Thèse lésions are much more constant in cases of cérébral hemorrhage, than 
those of motility ; and, up to the présent time, it has been impossible to detect, in 
the nature or in the seat of the altérations of the brain, the cause which sometimes 
suffers the sensibility to be intact, and sometimes produces its more or less com- 
plète abolition. 

We shall now consider thèse lésions of sensibility : lst, in the skin ; 2ndly, 
at the surface of the différent mucous membranes, capable of being touched ; 
Srdly, in the organs of sight, of hearing, of taste, and of smell ; 4thly, in the ence- 
phalon itself. 

1 . Lésions of the cutaneous sensibility. 

Thèse must be considered at two periods ; both before the hemorrhage has 
taken place, and after its occurrence. Before the period when the hemorrhage 
cornes on, many persons expérience nothing particular towards the cutaneous 
periphery ; but with others it is not so. The pulp of the fingers becomes the seat 
of divers sensations ; several complain of having in this part a singular feeling of 
cold, a sort of numbness similar to what is felt when the hand is plunged into 
frozen water ; others complain of pricking sensations, or annoying formication 
towards the extremity of the fingers ; others, again, fancy that there is a pièce of 
cloth interposed between the skin of their fingers and the body which they would 
touch : so much blunted is their sensibility. 

Thèse différent sensations may be confined to the hands ; they may extend to 
the feet ; they may even manifest themselves at other points, either of the extre- 
mities, or of the face or trunk. We have seen the case of a man, who before being 
struck with apoplexy, experienced from time to time complète loss of sensation in 
some isolated points of the skin of the thorax. Each of thèse points, which were 
to the number of five or six, might be about the size of a five franc pièce. There 
the skin might be pinched ever so severely, without the patient seeming to feel 
the slightest pain ; outside thèse points the sensibility was intact, and it soon 



114 



CLINIQUE MEDICALE. 



re-appeared in ail its integrity. Thèse partial abolitions of the sensibility were 
not constant ; there were some days when the sensibility was not diminished in 
any part ; then suddenly it disappeared from the parts just now mentioned. 
Another patient, after having left the La Pitié, where he had been treated for an 
intense erysipelas,prmcipally seated in the left side of the face, cranium, neck, and 
back, entered again at the end of two months with total loss of the sensibility of 
the différent parts of the skin, where the erysipelas had been. Thus the skin of the 
face of the left side, that of the scalp of the same side, and also that of the neck, 
from the médian line to the level of the top of the shoulder, had lost ail sensation. 
On this same side, hearing, sight, smell, and taste, were also nearly destroyed ; the 
motility of the parts affected had not, however, undergone any change. This 
patient had for the last six weeks experienced almost constant dizziness, and it 
was nearly since that same period that he commenced to lose the sensibility in ail 
the portion of the skin previously affected with erysipelas. Was there not in this 
case a spécifie affection of the fifth pair of nerves ? 

The perversions of cutaneous sensibility preceding the apoplectic attack, may 
develope themselves always in the same point, or seize on différent parts one after 
the other : they may manifest themselves on both sides of the Body at once, or 
confine themselves merely to one, and in the latter case the side which they affect 
will in gênerai be that which, at a subséquent period, will become paralysed. _ 

Nothing is more uncertain than the time intervening between the lésion of the 
sensibility and the apoplectic attack. In several cases we have seen the sensibility 
modified only a few days before the appearance of the symptoms of cérébral 
hemorrhage ; in others numbness, formications of the extremities, manifested 
themselves some years before the occurrence of the hemorrhage. 

Let us now trace the modifications which the cutaneous sensibility may undergo, 
after the cérébral hemorrhage has appeared. 

The abolition of sensibility does not always accompany loss of motion : when 
it does take place, it is generally seated in the parts, whose power of motion has 
been modified. We have seen some cases, however, in which it was not so. In 
a man, for instance, who entered the La Pitié, in the year 1831, we made the 
following observations :— 

This person, sixty years of âge, after having for a long time experienced a pain 
of the head, seated principally in the right anterior latéral part of the cranium, 
suddenly lost the faculty of seeing on the same side where the headach existed, 
and at the same time the pupil of the right eye was contracted in an extraordinary 
manner. For about six weeks the right eye remained thus deprived of sight, 
without any other phenomenon appearing. But at the end of this time the right 
side of the face lost ail sensibility, without its motive powers being at first in any 
way changed. From fifteen to twenty days the sensibility remained thus lost on 
the right side of the face, then the upper extremity of the left side became 
evidently weaker than the other, without the cutaneous sensibility in this extremity 
being changed, and nearly at the same period the muscles of the right side of the 
face began to become paralysed, and the mouth was slightly drawn towards the 
opposite side. There was not in this case the slightest loss of consciousness. 

We shall not here discuss what the lésion was, which in the individual. whose 
case we have just now mentioned, produced this double modification of sensation 
and motion ; we mentioned the case merely to point out the extraordinary cir- 
cumstance of loss of sensation on the right, and of motion on the left. In this 
case, again, there is another peculiarity : it is this, that the paralysis of motion 
came on in the left side of the face, that is, in the side opposite that of the 
paralysed limb. Now this circumstance establishes a strrking exception to the 
law which we previously laid down. 

According to the time which elapses from the apoplectic attack, the cutaneous 
sensibility re-appears, and most usually it is found almost completely re-established 



DISEASES OF THE ENCEPHALOX. 



llô 



at a time when the pàraJysis of motion still remains undiminished. However, the 
fingers often continue benumbed and cold ; but that may dépend in a great 
measure on the privation of motion producing a degree of languor in the capillary 
circulation. 

2. Lésions of the sensibility of the mucous membranes. 

In those cases where the sight is lost, the eyelids are made to approximate by 
touching the conjunctiva with the finger. There are, however, cases in which 
this membrane becomes so insensible, that the end of the finger may be passed 
over the entire anterior surface of the globe of the eye, without the eyelids ap- 
proximating, or without the patient's evincing the slightest sign of pain, and that 
at a time when in other parts the sensibility is still sufficiently acute. One of oui- 
cases furnished us with a very remarkable instance of that kind. This insen- 
sibility is similar to that which may be produced in animais by dividing the fifth 
pair of nerves. 

On introducing a feather into each of the nostrils, we ascertained in some 
apoplectic patients a notable diminution of sensation on one of the halves of the 
mucous membrane of the nasal fossae. Some have told us that on introducing 
their food into each side of the mouth alternately, there was one side in which the 
contact of the food with the mucous membrane of the mouth was felt much less 
distinctly than in the other. We particularly ascertained this diminution of sen- 
sibility of one of the sides of the mouth and one of the nostrils in an individual, 
the corresponding side of ail whose face was likewise deprived of sensibility, whilst 
the power of motion remained intact ; in no other part was it altered : sight and 
hearing were also much weaker on this same side than on the opposite side. 

Thèse différent modifications of sensibility seem to indicate that there are cases 
where hemorrhage of the cérébral hémisphères, whatever be its seat, exercises an 
influence on the fifth pair of nerves. 

3. Lésions of the funciions of the organs of the sensés. 

In a considérable number of cases vision is not modified. When it is disturbed, 
it may be so before the hemorrhage takes place, at the very time when it has 
occurred, or after its occurrence. 

Before the hemorrhage, several persons expérience, on the part of vision, strange 
sensations, real hallucinations. With some, ail objects appear to be coloured 
red ; other fancy that a red line borders ail bodies ; a sensation similar to what 
is experienced when the eyes have been for some time exposed to the impression 
of a strong light. There are some who cannot look attentively at an object 
without seeing it dotted with red or black points ; others have a constant mist 
interposed between their sight and the object they are looking at. Some are 
tormented by the appearance of Aies, which seem to them constantly dancing 
before their eyes. 

It must not, however, be supposed that thèse différent hallucinations of vision 
lead necessarily to cérébral hemorrhage. We have had an opportunity of 
observing a person who, for several years, was constantly tormented by the 
imaginary sight of small bodies of différent forms and colours dancing before 
his eyes : if he would look steadily at an object, he saw it dotted with a 
number of black points ; this hallucination, which was permanent, prevented 
his being able to read or write ; he had neither dizziness, vertigo, nor headach ; 
the conjunctivas were habitually red, and he could not endure without considérable 
suffering a more than ordinary strong light. 

Diplopia has been occasionally observed a certain time before the supervention 
of an attack of apoplexy. 

Other persons have been suddenly struck with blindness, and the loss of sight 
was with them the principal precursor of cérébral hemorrhage. We have seen 



116 



CLINIQUE MÉDICALE. 



a locksmith who, after having experienced considérable dizziness of the head for 
eight days, suddenly lost bis sight. After having remained blind for fîfteen days, 
he suddenly fell down deprived of eonsciousness, and paralysed on the right side ; 
consciousness soon returned ; the hemiplegia continued, but what was very 
remarkable, some time after the attack he began to recover his sight, which 
however continued very weak with him. We saw another individual in whom, 
during the month preceding the attack, the sight was completely lost three dif- 
férent times : he suddenly became blind ; the blindness continued from forty- 
eight to sixty hours ; he then recovered his sight. 

In a word, individuals have been observed, in whom, for some time before the 
attack, their vision acquired unusual sharpness. 

Such are the principal phenomena which manifest themselves as connected with 
sight, a longer or shorter time before the hemorrhage supervenes. Their existence 
proves indisputably, that before the blood is effused, there is already going on in 
the brain a morbid process, either continued, or intermittent, the nature of which 
it would be a matter of great importance precisely to détermine. 

Once the hemorrhage has come on, the sight may remain unafFected ; but it 
may also be lost. Sometimes it is lost on both sides ; that takes place in violent apo- 
plexy, when the hemorrhage is very extensive. Sometimes, on the contrary, the 
power of vision disappears only on one side ; but here, two différent cases have 
been observed : in the one case, the sight is lost on the side where the paralysis of 
the limbs exists ; in the other case, the patient does not see with the eye of the 
side opposite the paralysed side of the body. 

We have investigated how far the hemorrhage occupied a particular seat in 
those cases, where, after its occurrence, the sight continued affected, and this seat 
we have never been able to discover. We might cite cases here, either from our 
own practice, or which have been recorded by other writers, in which we might 
find différent altérations of vision, though the most différent parts of the hémi- 
sphères were the seat of the hemorrhage. We do not admit them, with M. Serres, 
that sight is lost only when the hemorrhage has its seat in the optic thalami, on 
the level of the commissure. We shall see, as we go on, that lésions of the 
cerebellum are also accompanied with différent disturbances of vision, and in 
particular with amaurosis. In the face of so many facts, which show us constantly, 
in the altérations of the brain, the most différent seats, to explain the disturbance 
of one and the same function, shall we deny that certain parts of the brain are 
particularly destined for the performance of certain acts ? We would have no 
right to do so ; for it is probable that certain points of the brain have such a 
relation among them, that the lésion of such a one among them will re-act, in 
particular, on such another ; and this will probably be the secondary altération of the 
latter, unappreciable by the scalpel, which is to produce the peculiar functional 
disturbance. 

The sensé of hearing may présent before, during, and after the cérébral 
hemorrhage, the same modifications as the sensé of vision. Before the hemorrhage, 
there are some who are annoyed with buzzing in the ears, continuai or intermittent 
tingling. Several fancy they hear the strangest noises. Thèse hallucinations are, 
however, far from being the constant prélude to an attack of apoplexy ; they may 
be connected with mere perversions of sensibility, and have nothing whatever to 
do with cérébral congestion 

We have no particular observations to make on the modifications produced in 
the sensés of taste and smell, by hemorrhage of the cérébral hémisphères. 

4. Lésions qf sensibility seated in the e?icepkalon itself. 

Pain of head, more or less intense, dizziness, vertigo, often précède cérébral 
hemorrhage. There are some persons, who, for several months, are constantly 



DISEASES OF THE ENCEPHALON. 



117 



affeoted vvith the signs of cérébral congestion ; one day it becomes more violent 
and the hemorrhage takes place. We cannot understand how persons can deny 
such a precursor, and assert, that it takes place only in cases of softening. We 
acknovvledge besides, that it is often completely wanting, and that individuals 
may be suddenly struck with cérébral hemorrhage, without ever having before 
presented the least symptom as referrible to the brain, without having ever com- 
plained either of headach, dizziness, &c. 

After the hemorrhage, there is no additionai phenomenon observed, we merely 
see the same symptoms continue in a great number of cases (such as vertigo, &c), 
as had been the precursors of the disease. 



CHAPTER III. 

LESIONS OF INTELLIGENCE. 

In the same manner as the lésions of motion and sensation, thèse aiso must be 
considered, before the hemorrhage has taken place, and after it has occurred. 

Several persons préserve ail the clearness and strengthof their intelligence upto 
the moment when they are struck with apoplexy. In others, there are observed, 
a shorter or longer time before this period, some changes in the intellectual 
faculties ; sometimes they are as it w r ere benumbed ; sometimes, on the contrary, 
they manifest an extraordinary excitement. Some patients lose their memory ; 
there are moments when they know neither where they are, nor what they do, nor 
what they say. We here give some instances of thèse aberrations of intelligence, 
which we have had an opportunity of observing. 

Awoman, whose reason had been up to that period perfectly sound,gave herself 
up ail at once, without any obvious cause, to violent fits of passion ; she became 
frantic, and was conveyed to the La Charité, in a state resembling mania ; on the 
very evening of her entering the hospital, she was struck with apoplexy, of which 
she died in less than thirty hours. On opening the body, we found in one of the 
cérébral hémisphères an enormous effusion of blood. 

A man, about fifty years of âge, forgets his ovvn name : he is from time to time 
convinced that he is dead ; he no longer recognises his own immédiate relatives ; 
he remains fifteen days in this state ; then he is struck with apoplexy ; the post 
mortem examination again shows, in this case, an effusion of blood within the 
hémisphères : no other lésion was discovered. 

Another man becomes incapable of attending to any occupation : he remains 
constantly seated, and his eyes, as it were, weighed down with sleep ; we could 
with difficulty elicit from him some few answers ; this state terminated by an attack 
of apoplexy. 

Several similar cases have been seen by practitioners ; they clearly prove that 
before the time the hemorrhage takes place, there may be already in the brain a 
morbid state, which is the precursor of it, and which may manifest itself by divers 
disturbances of motion, sensation, or intelligence. 

Other persons expérience, at several différent times, sudden losses of conscious- 
ness ; they fall suddenly into a profound coma, and it is supposed that they are 
under the influence of cérébral hemorrhage. But this coma disappears, and they 
are restored to perfect health, until a new coup de sang returns. At last, a time 
cornes, when, instead of a simple congestion, by which ail thèse phenomena might 
be explained, there cornes on a real hemorrhage, the effects of which are no longer 
transient, as those of the congestion which preceded it. 



118 



CLINIQUE MEDICALE. 



Even at the time the hemorrhage takes place, three cases may présent them- 
selves with respect to the modifications which the intelligence undergoes. 

In the first place, it is perfectly intact, and the serious altération which the 
power of motion then suddenly undergoes, brings no disturbance on the exercise of 
the intellectual faculties. 

In a second case, the intelligence becomes more or less dull, at the same time 
that the limbs are paralysed. The patient f'alls into a stupor ; others form inco- 
hérent résolves, or utter some unintelligible words ; however, they are still con- 
scious of the external world, and they are still able to hold relation with it. 

In a third case, on the contrary, the loss of consciousness is complète. The 
patients are plunged into a state of coma, from which the most energetic excite- 
ments cannot arouse them. Only sometimes, after being spoken to with a very 
îoud voice for the purpose of awakening them, they open their eyes slowly, and 
stare for some seconds on the person who is watching them ; but they soon 
relapse into their léthargie sleep. 

Thèse différences in the state of the intelligence at the time the attack of 
apoplexy takes place, dépend principally on the greater or less extent of the 
effusion. With respect to the seat of the latter, it has not appeared to us to 
exercise any great influence on the intellectual faculties. Not only have we seen 
the loss of consciousness coincide with hemorrhage in ail possible points of the 
cérébral hémisphères, but we have even found it in cases where the hemorrhage 
had its seat outside the hémisphères, in the cerebellum for example, or in the pons 
Varolii. Dr. Fabre has cited the very interesting case of an old man, who died 
of an attack of apoplexy, accompanied with complète loss of consciousness, in 
whom the nervous centres presented no other lésion than an effusion of blood 
into the substance of the left anterior pyramid ; a very striking example, no 
doubt, of the wonderful connexion which holds together and brings into unity of 
action ail the parts of the nervous System. 

After the effusion of blood has taken place, the coma may remain, the patient 
does not recover consciousness, and in this case death soon arrives. In the most 
favourable cases, and which are far from being rare, the state of coma disappears ; 
but once the individual has corne to himself, the intelligence does not always pré- 
sent the same conditions. In a very small number of cases, it is perfectly 
re-establîshed ; most frequently it remains enfeebled ; the patient retains sufficient 
reason to be able to attend to the concerns of common life ; but he has beconie 
incapable of deep or profound reflection ; he can no longer join, without distress, 
in a conversation of any length, or of a serious nature, and it is necessary to debar 
him from it, otherwise his state may be made worse. 

Instead of this simple weakness, the intelligence may présent a more serious 
altération. Thus we see a great number of apoplectic patients fall into a real 
state of childishness, or of senile dotage ; they shed tears with extraordinary 
facility. Others are seized, from time to time, with a delirium, which resembles 
that so often induced by acute inflammation of the méninges ; and, in fact, it may 
be supposed that in such cases it is caused by the occurrence of an irritation of 
the arachnoid which covers the affected hémisphère. Madness, in a word, has 
been seen to déclare itself after a cérébral hemorrhage. 

There is a phenomenon observed rather frequently after an effusion of blood 
into the brain : that is, loss of speech. It may exist with a perfect integrity of 
intelligence. Sometimes this accidentai dumbness soon disappears ; sometimes 
the speech is not recovered till after the expiration of a considérable time ; some- 
times, in a word, it continues for ever lost. 

Mr. Professor Bouillaud published, some years since, a paper containing some 
curious facts, from which he thought he might conelude, that the formation of 
speech has for its instrument the anterior extremity of each hémisphère, he having 
found this part the seat of lésion every time that, during life, speech itself had 



DISEASES OF THE ENCEPHALON. 



119 



been lost, What our researches on this subject have led us to conclude, is as 
follows : — 

Out of thirty-seven cases observed by ourselves or by others, relative to 
hemorrhages or other lésions, in which the morbid change resided in one of the 
anterior lobes, or in both, speech was abolished twenty-one times, and retained 
sixteen times. 

On the other hand, we have collected fourteen cases, where the speech was 
abolished without any altération in the anterior lobes. Of thèse fourteen cases, 
seven were connectée! with diseases ' of the middle lobes, and seven with diseases 
of the posterior lobes. 

The loss of speech is not, then, the necessary resuit of the lésion of the anterior 
lobes, and, besides, it may take place in cases where anatomy does not show any 
altération in thèse lobes. M. Lallemand* has cited a case in which there was 
found no other altération than a softening of the white substance of the left lobe 
of the cerebellum ; in this case, however, to which we shall take occasion to return 
for another purpose, the faculty of speech was completely lost. 

In M. Ollivier's work on the spinal cordf , you will find the case of an indivi- 
dual, in whom occurred the phenomenon of loss of speech, at first partial, and then 
complète. In this case, it was in the pons that the altération existed ; it was 
found softened at its lower surface to an extent equal, at least, to the size of a 
filbert. 



CHAPTER IV. 

LESIONS OF THE FUNCTIONS OF THE ORGANS OF NUTRITIVE LIFE. 

Among thèse functions, there is but one which is specially affected by cérébral 
hemorrhage ; and, again, the latter must be rather considérable, or, what cornes to 
the same thing, it must find the individual so predisposed, that a slight effusion 
will produce in the brain a greater disturbance than would seem to be compatible 
with the intensity of the lésion. Then the respiration présents a particular cha- 
racter, which is designated by the term stertorous. Must we admit, with M. 
Serres, that this function is particularly affected, in the case in which the hemor- 
rhage is seated in the optic thalamus and its radiations J ? 

The stertor of the respiration is, in gênerai, a very fatal sign ; and individuals 
who présent it in a marked manner, seldom escape a speedy death. To account 
for it, there is found in the dead body considérable infarction of the lungs, and a 
great quantity of frothy mucus in the bronchi. It is certainly in conséquence of 
the embarrassment of the respiration that persons struck with cérébral hemorrhage 
die, in the case where the attack is severe, and where they die promptly. 

The circulation présents divers disturbances : the heart frequently beats with 
strength, but this strength is rather in référence to its preceding state than to the 
cérébral disease itself. The puise is variable ; it is, however, more frequently 
slow than fréquent. The capillary circulation présents nothing observable, except 
towards the face, which assumes a différent appearance according to the indivi- 
duals ; sometimes it is red, considerably injected, and the conjunctivœ participate 
in this hyperemy ; sometimes, on the contrary, it is pale ; and it is now known 
that this paleness should not exclude the idea of a cérébral hemorrhage, and that 
it does not announce the existence of a serous apoplexy, as was supposed previous 
to the researches of Portai on this subject. 

* Letterii. p. 134. t Tom. ii. p. 614. % Anatomie Comparée du Cerveau, tora. ii. 



120 



CLINIQUE MÉDICALE. 



Among the phenomena which occasionally précède cérébral hemorrhage, or 
else which follow it, must be placed small effusions of blood, which take place in 
some persons into the tissue of the conjunctiva. 

The digestive fun étions présent no spécial disturbance, except frequently obsti- 
nate constipation, which is not always overcorae by drastic purgatives. It should 
be remarked, however, that the absence of alvine évacuations, in such cases, is far 
from indicating an insensibility * of the mucous membrane to the action of irri- 
tating substances brought in contact with it ; for we have frequently found a 
bright red injection on the internai surface of the intestine, and particularly of the 
large intestine, in persons wh-o had had no alvine déjection, though purgatives had 
been given them several days in succession, either by the mouth or the rectum. 
Observe, also, that if the employment of thèse means be continued, the tongue 
soon becomes red and dry, the puise becomes accelerated, the température of the 
skin is raised, and a gastro-enteritis soon cornes to add its danger to that of 
the cérébral affection. It would be an egregious error to suppose that, in such a 
case, the inflammation produced in the digestive tube acts as a révulsive, and 
must lessen the severity of the cérébral symptoms ; far from it, we have always 
seen the gastro-intestinal inflammation exasperate thèse very symptoms. Be- 
sides, this gastro-enteritis may itself avise spontaneously at a period more or less 
remote from that at which the hemorrhage took place ; and, in very many in- 
stances, it is of the inflammation of the intestine that old paralytic patients die, in 
whose brain there exists a hemorrhagie cavity of long standing. Most usually 
the gastro-enteritis then assumes the form called adynamic, and it is accompanied 
with the formation of eschars on those parts of the body on which any pressure is 
made. 

* An observation of Lallemand's, on the diminution of sensibility in the bladder, in affections 
of the brain, may not be here considered out of place : — " It is to tbe diminution of the sensi- 
bility that we must attribute the distension of tbe bladder, and tbe inflammation of its mucous 
membrane, observed so frequently in diseases of tbe brain and of its membranes, wben such dis- 
eases are accompanied with stupor, drowsiness, &c. The patient makes no effort to expel the 
urine contained in the bladder, because he does not perceive the impression made by it on the 
mucous membrane ; consequently it accumulâtes there, and distends its parietes as long as they 
admit of it ; then the résistance which the urine expériences from them beinggreater than that 
presented by the neck of the bladder and the urethra, according as a new quantity cornes into 
the bladder, it flows out in the same proportion, and with the same velocity as it is conveyed 
by the ureters, that is, drop by drop. As the patients are, in gênerai, soaked in the urine, 
persons suspect an incontinence, produced by paralysis of the sphincters, rather than the species 
of rétention of which we speak; the resuit of this prolonged sojourn of a great quantity of 
urine in the bladder is, that a potrion of it is absorbed, as is proved by the urinons smell which 
the transpiration often acquires ; it is partly decomposed there, as is demonstrated by its fetid 
odour, and the rapid altération of the silver cathéters, which, when drawn from the bladder, are 
found to be blackened, being covered, in fact, with sulphuretted hydrogen. After death, the 
mucous membrane of the bladder is found injected, and covered with patches or bloody points : 
the fundus of the bladder is often full of purulent mucus. The frequency of thèse inflamma- 
tions, the circumstances accompanying them, will not suffer us to consider them purely accidentai ; 
it is very probable that they are owing to the long continued impression of the urine, which is 
already partly decomposed." — Lallemand's Letters, ii. p. 236. It is évident, that when M. 
Andral dénies that the sensibility of the mucous membrane is affected, in brain affections, and 
when Lallemand assumes, that the sensibility of the mucous membrane of the urinary bladder 
is diminished in the same affection, they do not mean the same kind of sensibility. M. Andral 
speaks of the organic sensibility ; Lallemand, of the animal sensibility. The same reason for 
the cystitis in the one case will hold good for the gastro-enteritis in the other. — Tr. 



DISEASES OF THE ENCEPHALON. 



121 



SUPPLEMENT. 



SANGUTNEOUS CONGESTIONS AND EFFUSIONS AFFECTING THE SPINAL 

SYSTEM *. 

When we carefully examine the vascular System of the spine and spinal marrow, in indi- 
vidnals advanced in years, we are struck with the great number of dilatations which we find 
in the différent points of its extent. This phenomenon, which is frequently ohserved, results 
from numerous causes. Some dépend on the peculiar distribution and arrangement of the 
spinal vessels, particularly of the veins, which are entirely destitute of valves ; and though 
their anastomoses are considérable and fréquent, it is easy to see that the circulation in them 
goes on slowly, and with diffîculty, and that it may often expérience greater or less obstruction. 
I have frequently found in aged persons fibrinous clots filling ail the venous ramifications of 
the cord, as also those accompanying its nerves, clots the présence of which, resulting from the 
prolonged stagnation of the blood in thèse vessels, proved the slowness of the course of this 
fluid. 

On the other hand, the direct influence of the respiration on this portion of the circulatory 
System, produces in it numerous modifications, and becomes even the source of obstacles to 
this circulation, either in the state of health or of disease. This is what takes place in violent 
exertions, strong émotions, and in those affections which disturb in a more or less marked 
manner the act of respiration. From thèse considérations it is hard to think that repeated 
congestions in this deep-seated région should be without its influence on the functions which 
the spinal cord and its nerves are called on to fulfil, when we see the great disturbance pro- 
duced by a slight and a nearly analogous congestion in the functions of the brain. This 
■inalogy is real with respect to the effects of those congestions, but not with respect to their 
seat, for it is évident that here it is principally in the vessels external to the cord, and not in 
those of its tissue, that the afflux of blood exists. 

Thèse reflections were snggested from observing several individuals affected with para- 
lysis, sometimes gênerai, but incomplète, without lésion of the intellectual faculties, and who 
recovered sensation and motion after a shorter or longer time. I doubt not from différent post 
mortem examinations which I have made regarding this subject, but that we should attribute 
those symptoms to a more or less rapid accumulation of blood in the spinal vessels, an accumu- 
lation which itself becomes the cause of a more copious exhalation of the vertébral liquid. 
I have in gênerai remarked that the quantity of sérum in the vertébral canal was so much the 
greater, according as there was a greater congestion in the veins of the spine, and of the mem- 
branous coverings of the cord. Thus the slowness and diffîculty of the course of the venous 
blood may be here the causes of a dropsy, which is independent of inflammation of the spinal 
membranes, a fact of which numerous instances have been already cited for the other serous 
cavitiesf. 

Such is the source of the more or less painful numbness of the limbs with weakness of 
motion, which is remarked in certain persons, and which extends successively from the lower 
extremities to the trunk and upper extremities. The patients remain lying on their back in a 
state of gênerai but incomplète paralysis ; the movements of the thorax are sometimes lessened, 
and the respiration, which is in other respects regular, seems to be performed merely by the 
external respiratory muscles and the diaphragm ; the gênerai circulation does not seem to be 
sensibly affected. In this paralysis we often see patients gradually recover motion and sensa- 
tion, and the symptoms disappear from above downwards. The functions of the rectum and 
the bladder are but little disturbed, and the intellectual faculties remain intact. 

Before proceeding further, I shall insist on this latter circumstance to establish the différence 
which exists between this incomplète gênerai paralysis, and that which is oftentimes observed 
in lunatics, particularly those whose mental malady results from masturbation, venereal excess, 
abuse of spirituous liquors, prolonged use of mercury, great chagrin, fatigue, and exertion of 
mind : we also see it succeed to aliénations which have been accompanied with very violent 
agitation. In this species of paralysis, the embarrassment of speech is the first symptom which 
manifests itself, together with a defect of steadiness in walking ; this diffîculty in the motion of 
the tongue and of the lower extremities increases progressively and simultaneously ; the upper 
extremities then become heavier, their movements become embarrassed , and the individuals die 
after some years in a state of gênerai paralysis, more or less complète, with the remains of a 
sensibility more or less obtuse. 

The progress of this affection présents, as we see, a partkular character which distinguishcs 

* The above lias been condensed from Oilivier's Traité de la Moelle Epinièrc, &c, vol, ii., p. 448. 
t Dict. de M éd., art. Hydropsie. 



122 



CLINIQUE MEDICALE. 



it from that with which I am here engaged. The symptoms of a cerebra, lésion aceompany 
the paralysis of the lower extremities, whilst nothing similar is observed in the paralysis which 
results from spinal congestion, the persons on whom it manifests itself presenting no sign of an 
affection of the brain. What is more, we see in the numerous cases collected by M. Calmeil, 
that in certain cases the encephalon of lunatics présents nothing which can explain the pheno- 
mena observed during life; I doubt not that sanguineous congestions then contribute, and 
oftener than is supposed, to produce those lésions of motion and sensation — congestions, the 
traces of winch disappear sometimes at the moment of death, but whose existence is here so 
much the more probable, as the entire nervous centre is the seat of greater excitation, and of a 
more considérable afflux of the fluids. The facts which I give will render this opinion much 
more probable. 

When the congestion is very active, it may be accompanied with pains in the dorsal région, 
which extend from below upwards, according as the paralysis extends in the same direction. 
It is easily conceived that the serous exhalation, which increases from the moment the san- 
guineous congestion takes place, should contribute at the same time to increase the paralysis, 
by compressing the spinal marrow still more. The following case, taken at the Hôpital 
Necker, présents an example of thèse différent phenomena : — 

Case* 55. — Numbness of the lower extremities — Incomplète paraplegia limited to the 
lower half of the trunk, and extending progressively to the rest of the trunk and 
upper extremities, accompanied with pain in the back — Absence of csrebral symptoms 
— Successive disappearance of the phenomena — Cure. 

A man, twenty years of âge, a locksmith, entered the Hôpital Necker, the llth October, 
1822, presenting ail the symptoms of gastro-intestinal irritation, with continued fever. He 
had successively four copious nasal hemorrhages, on the 7th, 14th, 21st, and 28th days, 
without any favourable resuit. The symptoms did not cease to increase in intensity up to the 
30th day. From that period they diminished gradually to the 60th day ; convalescence 
was merely interrupted by some temporary relapses of the inflammation of the intestines. 
The cure appeared complète, and the patient now complained of nothing but gênerai debility, 
the resuit of his treatment, when one night having gone ont of bed, and walked a few steps (in 
February), he felt, on a sudden, a marked numbness in the lower extremities, which bent 
under him, and he fell. He was scarcely conveyed to his bed, when he threw up several 
times a considérable quantity of very liquid yellowish bile ; the skin was bot, and puise fré- 
quent ; no disturbance of the intellectual faculties ; the patient could not sleep. 

The following day, his state nearly the same ; paraplegia incomplète ; continuai formication 
of the skin, which somewhat impaired its sensibility. This numbness did not ascend higher 
than the epigastrium. An acute pain existed along the spine as far as the middle of the dorsal 
région ; motion increased it ; upper extremities completely free (ammoniacal frictions along 
the site of the dorsal pain, blister to the loins). He continued in the same state till the 
fourth day, when the pains of the back increased, they extended as far as the neck, and the 
two upper extremities were weaker and benumbed. The patient could not grasp anything 
firmly in his hands ; skin bot and dry ; puise fréquent. A blister was applied to the nape of 
the neck. The fifth day, the numbness of the upper extremities increased a little, as also the 
dorsal pains. Ever since the third day a small eschar had come upon the sacrum, as broad as a 
twenty sous pièce, which had not taken place during the entire illness, which had been very 
long, though he had constantly lain on his back, and his body was very much wasted. 

The sixth day, ail the symptoms began to diminish in intensity, and on the 4th of March he 
left the hospital, having recovered his strength and fiesh, and no longer feeling any annoyance, 
except a little weakness in the lower extremities, which has since completely disappeared. 

Is it not very probable, that the phenomena presented by this patient were the resuit of a 
very active spinal congestion, for we see here none of the symptoms characterising meningitis ? 
On the other hand, if we consider the multiplied connexions of the spinal marrow with the 
internai viscera, we shall be less surprised to see an affection of this nervous centre after an 
acute and long-continued gastro-intestinal irritation. This secondary affection was, in some 
degree, confirmed by the rapid formation of the eschar on the sacrum ; a phenomenon which 
was not observed up to that period, and which is generally common in the altérations of the 
spinal marrow or its membranes. It is probable that the accumulation of blood would have 
been less, if there had been applied a great number of leeches, or the cupping-glass, along the 
spine, instead of the irritating means which had been employed. Was there, at the same time, 
an increase in the serous exhalation, and a progressive absorption of the liquid ? This supposi- 
tion is not without foundation. 

I have already remarked what influence the respiration exercised over the venous circulation 
of the spine. It is easy then to conceive that if in a person disposed to such congestions as 
thèse, there should supervene any serious altération of the respiratory organs, the symptoms 



* Ollivier, toni. îi. p. 452. 



DISEASES OF THE ENCEPHALON. 



123 



rnay become intense ; the sanguineous congestion inereases more and more ; it also contri- 
butes to increase the difficulty of respiration caused by the pulmonary affection, and the patient 
dies in a state resembling asphyxia. I examined the body of an individual who had beeu 
affected with incomplète paralysis in the movement of the trunk and extremitie9, with morbid 
exaltation of the cutaneous sensibility. This paralysis, which in its course had followed the 
progress I have marked out, had gradually diminished, and was nearly gone, when it again 
appeared simultaneously with a pleuro-pneumonia. This latter disease made rather rapid pro- 
gress, and the paralysis was observed to go on increasing till his death ; so that a few days 
before he died the patient had relapsed into the same state of paralysis, with extrême sensi- 
bility of the integuments. The upper and lower extremities performed but very feeble and 
gênerai movements ; respiration was extremely painful, and the movements of the chest were 
almost imperceptible. He preserved to the last the free use of his intellects. 

At the post mortem, we found rather extensive pneumonia and pleuritis of the right side -, 
there existed at the same time considérable sanguineous congestion in ail the meningo-spinal 
veins, which were manifestly dilated. The nervous cords were enveloped in a collection of 
veins very much gorged with blood, which evidently compressed each spinal nerve at its exit 
from the spine, a circumstance which perfectly explained the phenomena observed during life. 
There was a little sérum effused. The spinal marrow and its membranes presented no other 
trace of altération, no more than the brain and its membranes. 

This sanguineous congestion of the spinal venous System was so much the more remark- 
able, as in another patient whom I opened soou after, and who had died of encephalitis, 
accompanied by a spinal meningitis, which was characterised by a puriform exudation between 
the pia mater and arachnoid of the spine, the spinal veins did not présent a similar engorge- 
ment, and yet the afflux of the fiuids which must have existed during the inflammatory pro- 
cess, could only cause a congestion similar to what we have just been examining. It appears 
évident that it alone sufficed to produce the gênerai stupor with which the trunk and extremities 
had been struck, for the accumulation of fiuid was not sufficiently abundant to warrant us in 
attributing to it the phenomena observed during life. They depended then solely on the vas- 
cular congestion, and in a great measure on that which compressed the nerves at their exit 
from the intervertébral foramina. 

Case* 57. — Abuse of venery — Incomplète paralysis of motion ofthe upper and lower 
extremities, without lésion of the sensibility — Slight pains in the loins — Absence of 
cérébral symptoms — Graduai disappearance of the paralysis from above downwards 
— Cure at the end ofthree months. 

M***, thirty-eight years of âge, of a sanguine tempérament and lively disposition, had 
always led, up to the day of his illness, an active and laborious life. He indulged in spirituous 
drink, and in venereal pleasures in the erect posture. The debility gradually produced by this 
indulgence obliged hira to put some restraint on himself. After an act of this kind, he expe- 
rienced a pain in the loins, and a trembling of the lower extremities. 

For the last two months, there was a gênerai debility of the legs, and wandering pains, 
which did not, however, prevent him from following the same kind of life ; when, on the 
15th of April, after a violent fit of anger, hefelt an almost universal trembling of the muscles. 
The 16th, after more labour than usual, numbness in the right hand. The 17th, he travelled 
some miles on horseback (the numbness still continuing), on which occasion he drank some 
spirituous liquors ; pains in the loins ; a sensation of breaking of ail the limbs. On the 18th. 
the family physician observed a difficulty in his movements, some unsteadiness in his walk ; he 
felt acute pains in ail the articulations, a sensé of formication in the hands, no altération of the 
features, no headach, respiration natural. 19th, face flushed, slight pain of head, same state 
of extremities, puise hard and accelerated. (Bleeding from the arm, baths, diluent drinks.) 

After some days, MM. Dutrochet and Gendron were called into consultation, and found the 
patient sitting in a chair in the following state : — Upper extremities inert, hanging over the 
thighs, sensible to the touch ; fingers move imperceptibly ; to raise the shoulder, and carry the 
hand to the forehead, the fore-arm slowly describes an arc of a circle in its direction toward 
the chest, and the head inclines in order to meet the hand, which scarcely touches the 
cervical région ; the left less capable of performing this movement than the right ; both thèse 
limbs fall again by their own weight. The patient cannot grasp anything in his hands. He 
raises the legs from six to eight inches from the ground, and they soon fall again ; toes 
immoveable ; no pains in the extremities ; merely a gênerai numbness ; and it is only after 
trying to perforai some movement that he expériences a sensé of formication. The movements 
of the muscles of tbe head and neck intact ; those of the back and loins abolished, so that the 
patient cannot rest on his seat ; the posterior part of the trunk, ail across the spine, not 



* Tom. ii. p. 464. 



124 



CLINIQUE MÉDICALE. 



affected with any pain ; a slight sensation of heat only in the dorsal région (twenty leeches 
applied at this part) ; skin in the natural state, puise slow, tongue free from redness ; respira- 
tion free ; pulsation of the heart conformable to the puise ; some slight colicky pains in the 
abdomen ; constipation ; function of the bladder well performed ; urine a little red. 

An antiphlogistic treatment was prescribed without any other effect than that of reducing 
the number of the puise. After the application of the leeches, the patient was deprived sud- 
denly of the little motion which had existed up to that time. The idea that an effusion 
might be the cause of this occurrence, made the médical attendants apply blisters along the 
spine, and have recourse to the internai use of tonics. By degrees the puise returned to 
eighty. 

After this treatment was followed up for fifteen days, the power of motion sensibly returned ; 
four blisters had been applied in succession. The patient objected to the application of any 
more of them. Obstinate constipation existed from the commencement of the disease ; this 
was remedied by purgative lavements. M. Bretonneau, who had been called in, ascertained 
instantly the existence of an almost complète muscular paralysis, with préservation of the sen- 
sibility. He recommended the use of moxas, but the patient refused. Nux vomica, given in 
gradually increased doses as far as thirty-six grains a day, merely produced formication in the 
extremities, and slight agitation for some nights. The patient complained occasionally of acute 
pains in the heels ; at last, annoyed at seeing no change in bis state, he determined on taking 
no more medicine ; only some dry frictions were occasionally made on the spine and the 
extremities ; by degrees the movements of the upper extremities became more sensible ; the 
patient was able to use bis hands in eating ; but bis legs could not support him ; he could rise 
and keep sitting without being fatigued; but when he wished to walk, he could with difficulty 
proceed three steps, and that in a very embarrassed manner by the help of crutches. After 
about three months' illness his health was restored, and the paralysis entirely disappeared. 

It would be difficult to admit, from the group of symptoms observed in this po,tient, that the 
cause of the paralysis consisted in an inflammation of the spinal marrow and its membranes. 
With ûie exception of the pain in the lumbar région, where no doubt the sanguineous con- 
gestion at the time of coition more particularly occurred, no phenomenon is observed which 
could well be connected with a well-marked irritation. Everything, on the contrary, an- 
nounces a cause which secondarily produced the torpor, and not the excitation of the spinal 
nervous centre, and this cause seems to me to have consisted in a sanguineous congestion, the 
fréquent récurrences of which infiuenced the exhalation of the vertébral liquid, whose quantity 
progressively increased : however the numbness which appeared in the right upper extremity 
after violent efforts, and when the weakness of the lower extremities had already manifested 
itself, might seem to prove that the afflux of blood did not take place in a uniform manner in 
ail the points of the spinal vascular System. It is very probable also, that the position in 
which this man habitually indulged in coition, and the gênerai contraction of the muscles 
which must resuit from it, could not but favour the spinal congestion. 

We should also remark the extraordinary weakness of the circulation after the use of an 
antiphlogistic treatment, a circumstance which equally tends to prove that there was not there 
an active concentration of the fluids as in inflammation. Perhaps also the enervating action 
of the venereal excesses had weakened the influence which the spinal marrow exerts over the 
circulating apparatus, and this cause may have added to the effects of the compression made 
on the nervous centre. Was it from this same circumstance, or rather because the seat of the 
altération was not in the tissue itself of the cord, that the nux vomica did not produce any 
resuit ? 

But how can the paralysis of motion take place without an altération of the sensibility, 
admitting thèse phenomena to be the resuit of a greater or less sanguineous congestion, and of 
the accumulation of a greater quantity of liquid in the vertébral canal. If we duly consider 
this morbid phenomenon, we shall find it hard to conceive that motion or sensation may be 
then separately abolished, since the spinal marrow should be equally compressed in ail the 
points of its surface. Yet when we reflect on its position in the spinal canal, we see at once 
that its anterior part is kept almost immediately applied against the posterior surface of the 
bodies of the vertebrse by the spinal roots, whilst the posterior portion is removed five or six 
lines from the corresponding surface of the canal. The resuit of this arrangement is, that if a 
fluid interposes itself around the spinal marrow, it exerts stronger compression on its anterior 
part in conséquence of being kept in closer approximation to the resisting part of its canal. 
On the other hand, if there be at the same time a congestion in the vessels of the pia mater 
which traverse the surface of the marrow, the effect of dilatation by thèse vessels, acting 
entirely on the anterior surface of the nervous cord, which can allow between it and the spine 
but a small interval, the anterior fasciculi are more particularly compressed ; thence it is that 
motion is more particularly affected by paralysis. 

I know that this explanation, rational though it may appear, would require to be support ed 
by the results of examination of the dead body ; but it is difficult that such phenomena, which 
can exist only under the influence of life, should continue after death. This remark is espe- 



DISEASES OF THE ENCEPHALON. 



cially applicable to the numerous lésions of the nervous System, and it is with goo 
M. Lallemand* has said, " that the pathological changes of the brain, the spinal mar 
of their membranes, are more difficult to be appreciated than those of other organs, 
that, independently of the particular précautions which their examination requires, ; 
inflammation, producing death more rapidly, leaves in them traces much less évident; 
a slight inflammation may more easily produce serious symptoms ; because that, b 
termination of ail the sensations, this nervous centre is more susceptible than any 
being sympathetically irritated, and it is to this difficulty of finding after death the 
those affections which were seated there during life that we must principally attribute 1 

ward state of our knowledge regarding thèse diseases." The following fact, cornu 

bv M. Dance, will prove the justice of M. Lallemand's observations : — 

Case 58-f- Labour natural— Suppression of the hchia on the third day — Conva 

without any return of the discharge. At the end of a month formication in the h 
foot of the left side, then of the right side — An almost sudden paralysis of the 
of the four extremities — Préservation of the sensibility — No lésion of the int< 
functions — Iwreasing dyspnœa — Death by asphyxia the second day — Coi 
though but Utile marked, of the spinal vessels— Brain and spinal marrow ini 
A woman, thirty-one years of âge, a servant, of a strong constitution, was conveyec 
2d of April, 1825, to the Hôtel Dieu in a state of gênerai paralysis ; intelligence not d 
She had lain in a month before : pregnancy and labour very favourable. The third 
milk fever set in, breasts swelled considerably, lochia entirely suppressed, and did not 
This did not seem to influence her health : she left the Maternité on the 12th day. 
end of eight days she resumed her duties as a servant ; when, on the lst April, afte 
been apparently in good health up to that period, she felt suddenly a sensé of creepin; 
at the ends of the Angers of the left hand, then at the extremity of the toes of the se 
and half an hour after, the same formication, first at the ends of the Angers of the rig 
then the right toes. 

Notwithstanding this disagreeable sensation, she continued to walk about till threi 
in the afternoon, when she was obliged to sit down, her limbs being no longer able te 
lier. She re-mained in this state, sitting in a chair, till seven o'clock, and her fatigue in 
she was unable to gain the bed, and it was necessary to carry her to it. She had soi 
in the night ; formication still annoying her. On the 2nd, following state : lies on 1 
face somewhat flushed ; countenance not expressive of suffering ; intelligence perft 
subject to headachs; had a slight one the evening before; formication at the ends of th 
and toes ; unable to raise her limbs, which, when raised, fall back on the back ; this 
more complète on the left than the right. The limbs not rigid, but flexible ; feet col 
the rest of the body ; patient feels this. 

Sensibility not diminished in any part of the body ; the slightest contact of the liml 
ceived ; Angers half-flexed, and she is unable to extend them. Respiration performe< 
sort of effort ; evidently cannot dilate her chest sufflciently, which resounds in everj 
percussion ; but auscultation detects a slight râle ; a gargouillement in the bronchi, e 
produced by the mucus collected in it, and which the patient is unable to expecto: 
movements necessary thereto being impossible (Up to this period her cough had bee 
easy.) Tongue moist and pale; slight colicky pains for the last hour; no alvine < 
since the commencement of the attack ; she passed urine, however, voluntarily during 
Température of skin natural ; puise rather weak and slow than otherwise ; appetite ; 
uneasiness any where except the sensé of formication. No pain along the spine, the c< 
tion of which is regular, on which there is no pain felt on pressure ; movements of 
on the neck free. (Bleeding from the ami.) At the end of an hour respiration more < 
chest dilates but imperfectly ; bronchial gargouillement more marked. At eight o'clo< 
evening dyspnœa increased ; marked contractions of the scalen muscles at each ins 
expectoration still impossible. (Sinapisms to the feet.) At ten o'clock suffocation s< 
less ; efforts to cough still incomplète. No sleep that night. The following mon 
3rd of March, the paralysis increased in the right hand ; sensibility still ; formica 
confined to the Angers and toes ; lancinating pain occasionally in the heel and big toi 
right side ; respiration a little more free ; disappearance of the mucous gargouillemen 
the ineffectuai effort at coughing obesrved the preceding day; passes urine voluntari. 
stipation continues ; face less flushed, and is covered with blackish veins, particular 
lips and cheeks ; température of skin the same ; puise quicker and stronger, but regul 
one hundred; déglutition more difficult. In the evening the difficulty of the respira 
more increased ; inspirations short and painful ; face violet colour ; skin covered witl 
puise from 120 to 130; beating of the heart strong and tumultuous. At eight o' 
night she was again bled ; dyspnœa increasing, cold and gênerai sweats ; patient complf 
of suffocation. At nine o'clock the circulation became slower, puise insensible, and thj 
expired at a quarter past nine. 

* Letter 1, sur l'Encéphale. f Vol. ii., p. 471. 



Î26 



CLINIQUE MEDICALE. 



Post moriem. Cavities of the cranium and spine were opened with the utmost care; 
marked engorgement of the vessels external to the cérébral dura mat^r, and of those coming 
from the diploe, particularly along the sutures, which gave to this membrane a violet tint. 
Nothing remarkable in the brain, except that on the surface of each section of it there were 
some red points, indicating a slight engorgement of this viscus. 

In the spine the cellular tissue, external to the spinal dura mater, was slightly infiltrated 
witb blood, particularly inferiorly. Spinal rnarrow, minutely examined, présentée! nothing 
unusual; its consistence rather increased. Lungs natural. The cavity of the utérus Hned 
with a reddish mucus. 

The différent circum stances of this interesting case cease to présent so much singularity, if 
considered with the preceding and the following cases. We shall see that vertébral sanguineous 
congestions in women, are more frequently caused by the suppression of a customary évacua- 
tion, and it is so much the more probable that here the sudden suspension of the lochia were 
the primary though remote cause of ail the S3 r mptoms so rapidly followed by death ; that M. 
Dance assured me, that he has frequently observed, at the Hôtel Dieu, the same phenomena 
in lying-in-women, after such a suppression, or that of the mille, or the cutaneous transpiration, 
&c. Let us now add a remark, which may explain the sudden invasion of the paralysis : it is 
this, that it was precisely a month after the suppression of the lochia, that the first symptoms 
were observed to corne on, a time when the periodical movement must exist, under whose 
influence the menses usually re-appeared, a coincidence which may account for the rapidity of 
the spinal congestion. 

But, it will be said, this concentration of blood in the spinal vascular System was not accom- 
panied with any dorsal pain, and the progress of the paralysis, which commenced in the left 
hand, then attacked the left foot, and from thence extended to the same parts of the opposite 
side, is no longer analogous to that, the symptoms of which have been described by me already. 
Thèse différences do exist, I admit : but was not this rapid accumulation of the fluids 
announced by the state of the puise, which ceased to be depressed as soon as ever the bleeding 
diminished the first symptoms of suffocation, and which became rapid and fréquent at the same 
time that the phenomena of active congestion in the spinal vessels increased in intensity? 
This violent fever could not be the resuit of the altération of any organ, as they were ail 
sound. With respect to the extraordinary progress of the paralysis, it does not prove that this 
symptom did not dépend on a simple vascular congestion ; for it is quite suffîcient to consider 
for a moment the spinal circulation in gênerai, in order to see that it may be the seat of partial 
congestions, more or less circumscribed, before the sanguineous congestion becomes gênerai. 
Thus we may explain the numbness of one separate limb, then of auother, &c. 

It cannot be admitted that the paralysis was produced in this patient by the cérébral conges- 
tion, which was very slight, as may be inferred from the state of the intellectual faculties, 
which remained intact up to the last moment. In fine, the increasing dyspnœa, caused at first 
by the restraint in the functions of the spinal cord, became in its turn one of the causes which 
concurred in embarrassing still more the action of this nervous centre. Here an objection may 
be raised, and apparently a very strong one, against the différent explanations I am after giving ; 
it is, that there were found on the dead body but slight traces of the sanguineous congestion to 
which I attribute ail the symptoms which presented themselves. No doubt, thèse traces were 
slight ; but is it astonishing that a sanguineous congestion so rapid, and which caused death in 
so short a space of time, did not leave behind it more vestiges of its existence? Ought we to 
be surprised that a phenomenon, merely vital, should disappear with the cessation of vitality? 
However, the sanguineous infiltration of the cellular tissue external to the dura mater, com- 
bined with the symptoms presented by the patient, sufficiently attests it. The results of the 
autopsy above recorded could not be objected to this opinion ; for, in this case, the patient had 
been affected for a long time with paralysis of motion in the trunk and limbs, and the repeated 
sanguineous congestions had insensibly dilated the spinal vessels, Which contributed to favour 
the stagnation of the blood in their interior after the individual died. Here, on the contrary, 
the invasion of the paralysis was sudden, and its duration very short; besides, deatu having 
been the resuit of a real asphyxia, the blood remained liquid, a circumstance which must again 
have contributed to facilitate the return of this liquid towards the central parts of the circu- 
latory apparatus in the last struggle. 

The influence of the venous circulation on the spinal marrow has been noticed by P. Frank*, 
who has made very just and well-founded reflections on this subject. The considérable quan- 
tity of blood found frequently in the veins and sinuses of the spine, the distribution of thèse 
vessels, in which the blood circulâtes against its own gravity, and without being aided by the 
action of valves, whilst its course is free and easy in the thorax and abdomen, are so many 
circumstances which fixed bis attention. Is it, then, astonishing, he says, that the suppression 
of an habituai flux, as the menses, or hemorrhoids, is so often accompanied with dorsal and 
îumbar pains more or less severe, and that we observe the'same phenomenon towards the latter 



* Delect. Opuscul., toin. xi. ; de Vert. Column., &<?.,an 1792. 



DISEASES OF THE ENCEPHALON. 



period of pregnancy, in certain chronic affections of the abdomen, in inflammation of the 
in its prolapsus, eversion, or in schirrus of the same organ, and in certain spasmodic 
Is it not, again, to the congestion and distension of the vertébral sinuses and the vertebr 
that we must attribute certain pains of the back and lower extremities, certain sciatic ne 
certain species of lameness, divers tremors and convulsive movements, stupor or para 
thèse extremities, as well as several epileptic and tétanie phenomena ? 

Such is the cause of those incomplète and transient paralyses, which appear in some 
affected with bleeding hemorrhoids, a little before their appearance, and noticed by Hippo' 
Aretaeus -f- observed the same phenomena after the suppression of a periodical hematu] 
Hoffman^ saw the same thing after parturition. Van Swieten§ has remarked that v 
produced similar effects. Frank saw a paralysis of both arms corne on after a violen 
ment, and go off spontaneously after some hours. Spinal sanguineous congestions a 
place, according to this last author, at the time of the shivering of fever, or consécutive' 
acute irritation of the intestines, considérable engorgement of the viscera, a contractioi 
aorta, or after an aneurism of this vessel ; they are then sometimes accompanied by paii 
dorsal and lumbar régions. I am almost certain, adds Frank, that the effects of respir; 
the spinal marrow are the same as on the brain, and that the vertébral veins and sinus 
expérience the same swelling, the same dilatation ; whence it follows, that there exists 
spinal canal, as in the cranium, a momentary plethora, when the lungs are under a mori 
prolonged restreint in their action. 

We see how just the différent reflections of Frank are, and how entirely they acee 
the preceding observations. This last remark, relative to the influence of respiration, 
firmed, by modem physiological experiments, and by numerous pathological facts. 
regard to the spinal congestions produced at the time of the shivering in fever, I do 
but they are also the cause of several other phenomena commonly observed on the appi 
fever, as the heat and pain of back, the sensation of fatigue, the pains and transient ni 
of the limbs, &c. phenomena which are so much the greater, if the sanguineous co] 
exist at the same time in the tissue of the spinal marrow itself. 

J. Frank || has also made some remarks regarding the influence of sanguineous con 
on the spinal marrow and its functions. He shows that " the arterial and venous cir< 
of the spine and spinal marrow must undergo numerous modifications, in the case whe 
exist any chronic engorgements of the abdominal viscera, or when the utérus is diste: 
the product of conception, or when repeated exertions act on the respiration ; on 
hand, because each intercostal and lumbar branch of the aorta sends into the vertébral 
branch which anastomoses with the spinal arteries, which are sometimes found dilated 
it were aneurismatic ; on the other hand, as many veins of the vertébral canal open 
intercostals, which terminate through the vena azygos in the vena cava superior, it i 
conceived that ail the altérations of the lungs, or of the right cavities of the heart, wh: 
cause any obstacle to the circulation, must produce in the spine a venous plethora. 
way may be explained the affections of the spinal marrow which supervene on a suppre 
the menses, of an hemorrhoidal flux, or of any other habituai hemorrhage." 

Ludwig**, a considérable time back, expressed ideas similar to those of P. and J. Frai 
is how he expresses himself on this subject in the chapter entitled Tractatus de Dolor 
Spinam Dorsi : " The very acute dorsal pains which so often exist in severe intestins 
dépend on the affection of the lumbar portion of the spinal marrow, which happens thr 
communication with the nerves of the great sympathetic. This organ is again the seat 
pains which seem to ascend along the back in certain cases of hemorrhoids, in schh 
cancer of the rectum. The sensation of tension in the back and loins, complained of by 
labouring under dysmenorrhsea, as also in certain cases of pregnancy, results also, acco 
the same author, frorn a similar irritation of the spinal marrow. In a word, he thinl 
p. 730) that at the onset of fevers, the wandering pains in the limbs, and in the dorsal 
dépend on the difficulty of the circulation of the blood in the vessels of the pia mate 
and spinal marrow. 

Thèse différent quotations are sufficient to prove that the attention of observers was 
fixed on the phenomena which resuit more or less directly from spinal sanguineous cons 
and on the causes which may concur in producing those congestions. 

I have already remarked that the most ordinary effect of venous congestions in gene 
produce, as the retardation or suspension of the course of the blood in the veins of i 
dropsy more or less circumscribed, according as the obstacle acts on one or more point 
venous circulation. This pathological phenomenon, of which numerous instances are i 

* Coac. Prœnot., No. 346. f De Morb. Diuturn., c. 3. 

f Med. Rat. Syst., part iv. p. m. 41. § Comment., tom. iii., p. 266. 

(| Praxeos Med. Univ. Prœcept., tom. vi. p. 26. Torino, 1822. 

% Malacarne, Encefalotomia Nuova Univ. Torino, 1780. 

** Advers. Med. Prac, tom. i. p 711. Leipsic, 1770. 



128 



CLINIQUE MÉDICALE. 



the valuable work of Morgagni, and which the still niore récent observations of M. Bouillaud 
have further confirined, would of itself suffice, if cases and observations did not prove it, to 
demonstrate, tbat when, by any cause whatever, the spinal venous blood is retarded in its 
course, or this portion of the vascular System becomes the centre of an active but moderate 
and frequently repeated fluxion, the quantity of the vertébral liquid iucreases, and must produce 
a greater or less compression on the spinal marrow. 

I have accordingly often observed with a well marked sanguineous congestion in the veins 
of the spinal marrow and its membranes, a greater quantity of sérum in the cavity of the latter. 
Several times have I fonnd considérable spinal effusions in old men who died after an attack 
of apoplexy ; in some the sérum was bloody, which resulted from the escape of a portion of the 
blood, which had been effused into the cranial cavity. The spinal serous collection, which is 
eituate between the pia mater and the inner reflexion of the arachnoid, is always sufficiently 
abundant in the dead body, since it distends ail the meningeal sheath during life. Tbe pré- 
sence of an abundant liquid, which usually fills ail the space between the spinal marrow and its 
membranes, was observed and described long since by Cotunnius*, the accuracy of whose 
observations (which, by the way, appeared to have been forgotten) were confirmed by the 
curious and récent researches of Magendie, who was the first to remark, that this liquid 
is truly sub-arachnoid, that is, that it is contained between the pia mater and the internai 
reflexion of the arachnoid. With respect to the communication of this liquid with that 
of the brain, it takes place by a small aperture described by this eminent physiologist f", 
and which is situated on a level with the termination of the fourth ventricle. It is 
through it that the liquid may flow from the cérébral ventricles into the spinal canal, 
and reciprocally from the canal into the ventricles. 

I thought it right to insist here, on ail the particularities relative to the vertébral liquid, as 
well to establish its constant présence as its quantity. It is then, évident, from the observa- 
tions of Cotunnius and Magendie, and from those which I have made several times on the 
dead body, that in the normal state, the spinal marrow is surrounded by a copious fluid, which 
distends the spinal membranes. Now, it is easy to conceive, that a slight increase in the 
quantity of this liquid, or that a vascular congestion to any amount may be sufficient to pro- 
duce on the spinal nervous cord, a compression, which instantly produces a numbness, then an 
incomplète paralysis of the extremities. Besides, do we not know, that a slight cause is 
sufficient to disturb the functions of an organ so délicate, and with which ail the nerves of 
sensation and motion communicate ? Thus, then, the présence of this liquid, necessary to the 
performance of the functions of the spinal marrow, as is proved by the results of its removal, 
at the same time renders this organ more susceptible of feeling the influence of the slightest 
pressure. The rapidity with which it is re-produccd, evidently proves its importance. That 
this fluid fills the entire spinal canal during life, lias also been proved beyond a doubt ; and 
hence the difficulty of appreciating, in the dead body, whether the quantity of sérum found is 
the resuit of dropsy, or of the normal state. In gênerai, irritation of the spinal méninges, 
whether immédiate or consécutive to an altération of the bones, contributes equally to increase 
this exhalation On the other hand, there have been occasionally observed during life, 
phenomena which announced a greater or less irritation of the marrow and its membranes, in 
persons whose vertébral canal, being opened after death, seemed to contain a quantity of sérum 
more abundant than natural §. 

The free communication of the cranial with the vertébral liquid, very well explains how 
spinal dropsy may supervene after birth consecutively to a hydrocephalus. Morgagni gives a 
very remarkable case of this, recorded by Genga || . Morgagni reports several cases of serous 
apoplexy with effusion into the spinal canal, which effusion he considers to arise from the 
cranial cavity. However, it also happens that hydrocephalus and serous effusion of the cranium 
do not give rise to a more abundant quantity of sérum in the canal of the spine ; as I have 
proved frequently in dissecting children who died of hydrocephalus. This phenomenon, 
apparently contradictory to what has been previously stated, may be readily understood by 
observing what takes place sometimes in cérébral dropsy. The liquid, in dilating the cérébral 
ventricles, rnakes, posteriorly, on the aqueduct of Sylvius, a pressure sufficient to close up this 
canal. Henceforward then, no more liquid can flow into the vertébral canal. This takes place 
principally in the case where the fluid pushes back posteriorly the cul de sac formed by the pia 
mater, which Bichat described as a canal of the arachnoid. 

If we may judge from what has been now stated of the difficulty of finding, on the dead body, 
traces of certain sanguineous congestions of the marrow and its membranes which have existed 

* De Ischiade Nervosâ Comment., in Sandifort, Thesaur. Dissert., tom. ii, p. 411, et seq. 
1764. 

-|- Journal de Phys. Exp. Jan. 1826. 

X See Morgagni de Sed. et Caus., Epist. x. sect. 1 3 

§ See Bonnet. Sepulchr. tom i. p. 305. 

j] De Sed. et Caus,, epist. xii. sect. 9. 



DISEASES OF THE ENCEPHALON. 



during life, we also see that it is most frequently impossible to appreciate whether the 
of the liquid is really increased so as to constitute a real hydrorachis, or spinal dropsy, s 
membranous canal of the spinal marrow is entirely filled with sérum during life, and the 
lation of it is more considérable in old âge, in conséquence of the atrophy of the nervous 
and a slight increase in its quantity is thus sufficient to produce stupor or numbness of tl 
and extremities. Be that as it may, it appears to me certain, that venous congestions an 
effusion, whether existing separately or simultaneously, are, under certain circumstai 
real cause of nervous affections, independent of any morbid change in the tissue of tl 
marrow, of its nerves, or its membranes. Spinal meningitis may, no doubt, give rise t< 
copious exhalation of sérum, but there is then observed a regular train of spécifie syi 
and though this inflammation may be, in some measure, nothing but the same phen 
differing only in the rapidity of its progress, I thought it right to examine it separatelj 

Case 62 A soldier, of an infantry régiment of the line, twenty-six years of âge, re 

thrust of a foil in the left temporal région, and instantly fell. When brought to the 
he was in a profound stupor. Respiration difficult and slow ; at each expiration a frotl 
escaped from his mouth ; convulsive movements agitated lus limbs. He was bled witl 
effect. Respiration became slower, and he died three hours after the accident. 

Post morteni. A rounded and even perforation, about the size of a line and half 
direction, at the inferior and anterior angle of the left pariétal bone, directly in th 
which lodges the meningeal artery. Effusion of black blood, a little coagulated, over tl 
surface of the lobes of the brain, as also at the base of the skull, where it was more al 
The sinuses of the dura mater were filled with black blood. ' The foil, in entering th 
of the pariétal bone, had pierced the meningeal vein, without at ail touching the m 
artery. The substance of the brain was not perceptibly injected ; the instrument hi 
trated about an inch into the cérébral substance. It was not observed that it ent 
ventricle of this side, the cavity of which, as also that of the left ventricle, were, 1 
filled with fluid black blood. 

Spine. — On allowing the neck of the body to hang over the edge of the table, after r 
the brain, I remarked that there flowed from the spinal canal, a great quantity of blacl 
very fluid, and still warm. After opening the spine I found the cavity of the spinal me 
still filled with this fluid, though a great abundance of. it had escaped from it before op< 
A frothy red blood raised the inner reflexion of the arachnoid, which was united but lo 
the pia mater by cellular bands. The medullary portion of the medulla oblongata wf 
without any perceptible injection, and of ordinary consistence. 

It would be wrong, no doubt, to draw from this case any arguments to illust: 
symptomatology of sanguhieous effusion into the spinal membranes, because the w 
the brain, and the accumulation of blood in the ventricles, and at the surface of thi 
must have contributed to produce the symptoms which preceded death. Howeve 
inclined to think, from the récent experiments of Magendie, that the blood which flo 1 
the spinal sheath may have concurred in determining the gênerai convulsions observed. 
effused, as bas been seeu, partly between the pia mater and arachnoid, and partly into 
cavity of this latter membrane, a circumstance which is explained naturally by the r 
the wound. May not this fluid, differing from that which natui'ally fills the men 
canal of the spine, have acted as an irritating body on the spinal marrow and its 
thence the convulsive movements of the limbs. 

Case 64.* — Spontaneous hemorrhage and rupture of the cephalic bulbof the 
marrow and of the annular protubérance— Convulsive contractions of the 
Stertorous respiration — Death at the end of five hours. 

M t D., amiddle-sized man, large head, short neck, broad shoulders, and large abdon 
muscular, being at work in the open air, complained suddenly of a ringing in the ear 
minutes after he screamed from acute pain ; he arose, commenced to run, as if to es 
danger which threatened him. After having run for a short distance, he fell, and p 
the following symptoms : — 

Complète loss of consciousness ; face pale ; immobility of the pupil, which is not 
and is of the same diameter on both sides ; eye-lids at first half closed, and comph 
proximated (the upper lid of the right side fell a little subsequently to the left) ; im 
of the globe of the eye ; mouth half open ; tongue covered with arterial blood, and occ; 
protruded, but without permanent déviation of its point ; lips covered with frothy sa 
perceptible tension of the mouth. 

Respiratory movements fréquent, irregular s accompanied occasionally with steri 
almost continually with a sound similar to that which is fréquent in attacks of epileps 
eise nasi contract convulsively with the muscles of respiration. Twice there was 

* Ollivier, tom. ii. p. 511. 



iSO 



CLINIQUE MÉDICALE. 



sneezing, during which the patient, who lay on his back, bent forward. The limbs in a state 
of rigidity, which is easily overcome. This contraction, besides, is not entirely permanent ; 
it ceases for some moments, and then the limbs are pliant enough, particularly the arm of the 
right side ; the contraction then manifested itself suddenly, and lasted sorne tiine. In a word, 
thèse contractions seemed to hold a médium between tonic and clonic convulsions, thouarh they 
approached nearer to the latter. The contraction of the muscles of the neck was not strong 
enough to prevent the head, in obédience to the laws of gravity, from inclining to the right or 
to the left, forwards or backwards, according to the position given to the patient. With 
respect to the sensibility, it was hard to détermine whether it was abolished or not. There 
was observed a convulsive movement of the right arm when its skin was pinched, and a similar 
movement when the integivments were eut in bleeding him. Were thèse movements owing 
to the pain experienced by the patient ? Some contractions of the right arm during the 
bleeding manifestly increased the force and size of the stream of blood. 

In considering the almost convulsive contractions of the limbs, during which the arms were 
rotated inwards, and the strongly flexed state of the thumbs, and the froth with which the 
mouth was covered, one would have thought it a fit of epilepsy ; but the patient never presented 
any symptom of this disease. He died five hours after the first appearance of the disease. 
He was not observed for the last two hours. On examining the body } the central pro- 
tubérance was found changed into a pouch fiiled with blood, partly coagulated, and mixed with 
some fragments of nervous substance, softened and coloured by this liquid. This effusion 
made its way laterally by a small opening ; but the principal rupture existed in the fourth 
ventricle, the fioor of which, divided transversely, had given issue to the blood which distended 
the parietes of this ventricle. 

It is to be regretted that this patient was not watched closely up to the time he died, 
because the gênerai paralysis which must have preceded it might have been ascertained. It 
cannot be doubted but that this spontaneous hemorrhage produced the cessation of motion and 
sensibility, when it occasioned the lacération of the entire substance of the spinal bulb. But 
if this case be incomplète in this respect, it is still very important, in its establishing the 
diagnosis of the effusion from its commencement in this portion of the cerebro-spinal System. 
Thèse symptoms are truly characteristic, and présent no analogy to those which are peculiar 
to other cérébral hemorrhages. I have since had several opportunities of observing this 
apoplexy at the moment of tbe attack, and I have always remarked convulsive contractions in 
the upper extremities, with alternating movements of rotation inwards. The opening of the 
mouth underwent no change. Thèse spasmodic convulsions, observed at the commencement of 
the attacks of apoplexy in gênerai, seem to me to dépend on the irritation which the blood 
produces on the extremities of the torn medullary fibres, with which it remains in contact, and 
on which it must act as an irritant. 

With respect to the gênerai paralysis of the upper and lo ver extremities, it bas been 
uniformly observed, in ail casos where, at the post mortem, there has been found an apoplectic 
cavity in the substance of the protubérance and peduncles. M. Serres* saw several instances 
of this hemorrhage, and always, he says, complète immobility of the trunk and upper and 
lower extremities took place at the same moment when the apoplectic attack showed itself. 
Thus, I hesitate not to assert, that paralysis existed during the last hours before the death 
of the person who is the subject of the preceding case. 

In the first moments we saw that the respiratory movements were executed freely enough, 
and were even voluntary, since the patient sneezed twice, in doing which he flexed the trunk 
forward, and we know that this movement of respiration requires an effort of expulsion, which 
is impossible when the action of the respiratory nerves is abolished. It is probable that the 
hemorrhage, confiued to the protubérance, and to some fibres of the corresponding portion of 
the peduncles, did but lacerate them progressively, whilst it extended itself towards the 
cephalic bulb, a point where the rupture was soon followed by death. The manifest move- 
ments made by the patient, when pinched, and when his skin was eut in venesection, show 
that, at the commencement, the sensibility was not extinguished ; and this circumstance is 
precisely conformable to the seat of the hemorrhage, which at first occupied, as we have seen, 
only the anterior fasciculi of the spinal marrow. 

Death is so much the more rapid, according as the hemorrhage is more abundant, and the 
more it involves the cephalic bulb of the spinal marrow. The respiration becomes more difli- 
cult, and stertorous also ; it becomes progressively retarded, and the patient dies of real asphyxia ; 
sometimes, too, the lungs are found einphysematous. M. Serres quotes two facts which prove 
that life may still continue a long time, notwithstanding the paralysis of the upper and lower 
extremities, consécutive on hemorrhage of the protubérance. He met in two subjects, even in 
the midst of the pons Varolii, a cavity containing a yellowish fluid : there was an induration 
of the surrounding cérébral substance. The numerous excoriations on the posterior parts of 
the body in both subjects, évident marks of a long-continued lying on those parts, the atrophy 

* Annuaire des Hospitaux, p. 331, in 4to, 1819. 



DISEASES OF THE ENCEPHALON. 



131 



of the upper and lower extremities, equal on both sides, were évident proofs of a paralysis of 
long standing, consécutive on the effusion into the protubérance, which was partly absorbed*. 

It is then particularly when the hemorrhage interrupts the continuity of the fibres of the 
peduncles, that effusion at the protubérance gives rise to paralysis of the four extremities. 
But if the hemorrhage be inconsiderable, and the apoplectic cavity very much circumscribed 
and situated in the médian line, the fibres of the anterior cords are but little altered, the 
gênerai paralysis but little marked, and the individuals may live a longer time. 

The effusion which is seated in the annular protubérance, is situated therefore above the 
interlacement of the fibres of the pyramids : now if thèse fibres are completely divided only on 
one side, we observe exactly the same phenomena as those which resuit frorn the hemorrhage 
which takes place in the parts of the encephalon which préside over the movements of the leg 
and arm ; in a word, hemiplegia supervenes. The following example will furnish the proof of 
this pathological fact : — ■ 

Case 65 f Hemorrhage circumscribed to the left half of the protubérance, involving 

the fibres of the left peduncle — Hemiplegia of the right side — Death at the end oj 
two days, after a cérébral congestion — Cancer of the heart. 

Isidore Magriz, forty-six years old, entered the hospital Salpétrière for a complète hemi- 
plegia of the right side, which existed for several years. There was nothing particular in 
her state until some time after, when she suddenly felt a dizziness with loss of consciousness. 
Face injected, puise strong, &c. ; in a word, ail the symptoms of strong cérébral congestion 
manifested themselves. In spite of every means being resorted to, she died two days after the 
appearance of the first symptoms. 

Post mortem. Outward appearance. — Countenance very much injected. and of a violet 
hue, as also the conjunctiva, and eye-lids, which were swollen. 

Cranium.— Much black blood between the arachnoid and pia mater; the grey substance of 
the circumvolutions were of a deep colour ; white substance injected, and presented some 
slight marbling ; ventricles contained a considérable quantity of sérum. On cutting the annular 
protubérance layer by layer, there were found in the midst of its left half the évident toces of 
an effusion which had been absorbed : a circumscribed cavity, filled with a filamentous tissue 
infiltrated with yellowish sérum, and capable of containing an ordinary sized kidney bean : its 
greater diameter, of about five lines, was situated almost transversely, and a little obliquely 
frorn within outwards. This cavity of an old effusion partly absorbed, evidently interrupted 
the continuity of a great part of the fibres of the left peduncle. 

Thorax. — Lungs gorged with black, fluid blood ; pleurse contained several ounces of sérum. 
The muscular fibres of the parietes of the right ventricle of the heart were evidently changed 
into a yellowish white, encephaloid tissue. 

Abdomen. — Mucous membrane of the stomach thickened and of a brown red. Liver and 
spleen gorged with blood. 

This case, interesting in more respects than one, proves then at once that the hemorrhage 
which takes place in a part of the annular protubérance, may produce the same results as that 
which takes place in the optic thalami and corpora striata of one side of the encephalon, and 
that similar effusions, when they are not very extensive, are capable of absorption, just as those 
of the brain. Nothing, indeed, can distinguish this hemorrhage frorn the cérébral apoplexy 
which gives rise to hemiplegia. 

The paralysis which results frorn an effusion into the cérébral protubérance is always limited 
to motion, because the rupture involves only the anterior fasciculi of the spinal marrow. It is 
susceptible of cure, as well as that which dépends on hemorrhage which takes place in the other 
parts of the encephalon, and this favourable termination is effected by the same mechanism. 
The case I have now detailed présents an example of the progressive absorption of the effused 
blood, and proves that the primitive effects of the effusion still continue when the continuity 
of the medullary fibres has been interfered with. I shall, on this subject, make one remark, 
which is equally applicable to cérébral hemorrhage : it is that paralysis may disappear in cases 
where the blood resulting frorn the hemorrhage is effused between the medullary fibres, which 
it only séparâtes, and which it compresses without destroying them ; whilst, if their rupture 
takes place, the cure is never complète, and whatever means be employed, the effects still 
continue. I am certain that to this cause al one, already pointed out by M. Fo ville, and not 
to a cicatrisation of the torn medullary fibres, we should attribute the disappearance of the 
hemiplegia in certain individuals. It is easy to conçoive, in fact, that the paralysis resulting 
frorn the compression made by the effused blood on the nervous fibres in separaling them, will 
diminish according as this compression ceases in conséquence of the absorption of the blood 
and the contracting of the apoplectic cavity. The hemorrhages which tear more or less rapidly 
the tissue of the spinal marrow, présent then the same phenomena as those which burst into 
the lobes of the cerebrum and cerebellum. The altération and the tissue being of the same 



* Loc. Cit., p. 355. 



-J- Olliv. p. 525. 



132 



CLINIQUE MÉDICALE. 



nature, the effects must necessarily bear a resemblance : I abstract hom the symptoms, which 
difFer in more than one respect in thèse différent cases. An active and sudden congestion is 
folio wed by hemorrhage, by effusion of blood in variable quantity, and by a paralysis more 
or less prompt ; but when tbe sanguineous congestion takes place less rapidly, -when it is more 
continued, the nervous tissue undergoes an altération intermediate between inflammation and 
hemorrhage properly so called ; this continuai afflux of fluids brings on by degrees the soften- 
ing of the medullary substance ; the blood infiltrâtes and unités itself with it in some measure, 
and if the congestion continues, the nervous tissue is changed into a reddish, diffiuent, soft 
consistence, mixed sometimes with liquid and pure blood. In this case the paralysis developes 
itself but gradnally, and this disorganisation of the spinal marrow, prepared in some measure 
by repeated and constant fluxions, may sometimes rapidly destroy this nervous centre to a 
considérable extent. 



THIRD ORDER. 

OBSERVATIONS ON SOFTENING OF THE CEREBRAL HEMISPHERES, 

The excellent works published in later times, on softening of the brain, by 
MM. Rostan, Lallemand, Bouillaud, and ot'hers, are far, in my opinion, from having 
exhausted this subject. Science as yet possesses only data oftentimes incomplète, 
either to establish with précision the nature of this affection, or even to assign it 
its real symptoms. I do not think, for instance, with M. Lallemand. that a 
sanguineous congestion always précèdes softening of the brain ; I think that there 
are some cases, where the first appréciable lésion consists even in the diminution 
of the consistence of the nervous pulp, and this diminution of consistence may 
continue the only altération. Instead of being reddened by blood, the part 
softened may have preserved its natural colour, or even présent a remarkable 
want of colour, wifhout, in the latter case, any thing warranting us in thinking, 
as M. Lallemand had admitted, that pus infi.ltrated the nervous pulp so divested 
of colour. Softening of the brain does not necessarily commence by an hyperemia ; 
it is not necessarily complicated, during its course, even with sanguineous con- 
gestion ; neither does it necessarily lead to suppuration ; it exists as a lésion 
independent of any other lésion ; it is not, uniformly, either the termination or 
commencement of any other, but many others may accidentally become complicated 
with it. In several cases, it is true, during its isolated existence, it is but one of 
the éléments of inflammation of the brain ; but because the irritation produced by 
the entrance of a bail into the brain, causes around this foreign body the forma- 
tion of a softening, with sanguineous congestion, infiltration of pus, &c, is that, 
in sound logic, a reason for concluding that every softening should be considered 
as an inflammatory disease ? 

Ail that we can discover, in a very great number of cases, is a diminution in 
the consistence of the nervous pulp, its change into a sort of bouillie, its slow or 
quick return to this half-liquid state, which was its primitive state. With respect 
to the causes of this altération, they often escape us ; with respect to its nature, 
even that is not known to us ; and if, in this state of ignorance, we go beyond 
'* T hat facts teach us, if we assert that every softening is an inflammation, a degree or 
form of that, which, in a language altogether arbitrary, we call an encephalitis, we 
do great injury to science ; for, it is quite clear, that, the moment we shall have 
placed such an opinion between our own understanding and facts, the latter will 
be no farther admitted by us, but so far as they shall corne to confîrm our 
hypothesis ; there will thenceforth be a stop to ail further progress. I think 
then with M. Rostan, that, until more is known on the subject, the term softening 
is préférable to any other to designate the altération of the brain we arc uow 
about to consider. 



DISEASES OF THE ENCEPHALON. 



133 



What shall I now say of the symptoms which have been assigned to softening 
of the brain ? Read the several works published on this subject, and you will be 
astonished to see how much the symptomatology varies in them ail. Such a 
morbid phenomenon, permanent flexion (contracture), fur instance, which with one 
observer holds the first rank among the symptoms, is scarcely mentioned by 
another. It is the same with pain of head, disturbance of the intelligence, &c. 
The first phenomena which mark the existence of cérébral softening, are equally 
far from being described identically by différent authors. For some persons it is 
always easy to distinguish, by the différence of their commencement, a hemorrhage 
of the brain, and a softening of this organ ; for others such a distinction is often 
impossible. 

Thèse différences of opinion are no doubt attributable to this, that each author 
has made his observations on subjects placed in conditions différent in respect of 
âge, and constitution, whence there resulted, with regard to the symptoms, so many 
spécial forms of the disease. Each person thus judging only from the point of 
view where he happened to be placed, has been able to discover only one side of 
the facts, and thus he remained incomplète in their description. I have endea- 
voured to avoid this rock by proceeding in a différent course. After having 
detailed a certain number of cases, calculated to point out the leading différences 
which may be presented by softening of the brain, with regard to its symptoms, 
its commencements, its duration, and its nature, I have endeavoured to attain 
the most complète description possible of this affection, by combining with the 
facts collected by myself those previously published by différent authors. 



SECTION I. 

Particidar Cases. 

1 have ranged the cases in a certain number of groups, which are reduced to 
the following : — 

In the first group, I have placed some remarkable cases in which cérébral 
softening remained completely latent. 

The second group includes cases in which the only functional disturbance on 
the part of the nervous centres was a lésion of motion, a lésion far from being 
always the same. 

To a third group I attached some cases where the lésion of sensibility was the 
prevailing phenomenon. 

To a fourth group I referred other cases, where with varied disturbances of motion 
and sensation, an altération of intelligence or of speech coincided. 

Finally, in a fifth group, I have detailed cases where the only functional dis- 
turbance was loss of speech. 



CHAPTER I. 

CASES WHERE NO SYMPTOM ANNOUNCED THE SOFTENING. 

Case 1. — This was the case of an old man, eighty-one years of âge, who had 
jeen for a long time deprived of ail appetite for food : he sank gradually, and 
died in an adynamic state. At the autopsy there was found a softening at the 



134 



CLINIQUE MÉDICALE. 



base of the anterior lobe of the left hémisphère ; around the softening the cérébral 
substance gradually recovered its natural consistence, without being changed in 
colour. A broad eschar formed on the sacrum : a blackish tint of the viilosities of 
the stomach and duodénum was the only lésion found in the digestive organs. 

Case 2. — This was the case of a man forty-five years of âge, who laboured 
under a chronic affection of the stomach and liver. He complained of pain in the 
right hypochondrium, where there was found a hard tumour, painful to the touch. 
Whilst in the hospital, he had several times vomited an abundance of black 
matter : he died of exhaustion, but never had the least disturbance with respect 
to intelligence, or the power of motion ; and yet, at the post mortem, there was 
found extensive softening of the cérébral hémisphères in several parts. 

Case 3.— Softening of the posterior lobe of the left hémisphère, of the middle 
lobe, of the right lobe, and of the fornix. No symptom, however, indicated this. 
There were cancerous products in the pleurae, mesentery, liver, pancréas, and 
one of the kidneys. 

Case 4. — This was the case of a man, fifty-five years of âge, who had been 
wounded in the head in the Russian campaign; as a vestige of this wound there was 
a perceptible dépression, the size of a five franc pièce, on the middle part of the left 
pariétal bone, yet he complained of no headach; intelligence perfect; his sensés and 
speech ail perfect ; he died in the hospital of phthisis. On the post mortem the cir- 
cumvolutions of the brain, corresponding to the site of the wound, were softened ; 
the bone over this part had been completely destroyed, and nothing but a mere 
plate of cartilage was interposed between the hairy scalp and the brain ; the arach- 
noid and pia mater were very much thickened in this part. 



CHAPTER IL 

CASES WHERE THE DISTURBANCE OF MOTION WAS THE ONLY SYMPTOM. 

It has been stated, that in softening of the brain there was a period of the dis- 
ease when the limbs presented the phenomenon of softening in différent degrees. 
We shall endeavour to show in the following cases, that this phenomenon, though 
very fréquent, is not constant, and that in its stead we may meet either simple 
paralysis, or other disturbances of motion ; such as convulsions or tétanie rigidity. 
We shall commence with cases wherein the flexion (contracture) took place tran- 
siently or permanently. 

Case 5. — This was the case of a woman, sixty-six years old, who entered the 
hospital with ail the symptoms of diseased heart. After some days she found lier- 
self unable to move the extremities of the left side ; lier fore-arm also was strongly 
flexed on the arm, and the Angers so flexed that their ends touched the palm of 
the hand : no pain in the parts fîexed ; their sensibility perfect ; intelligence and 
speech natural ; no headach. The third day from the appearance of the flexion 
of the fore-arm and Angers, her habituai dyspnœa increased, and she died in a 
state of asphyxia in the course of the night. 

Post mortem. Cranium. — Several of the circumvolutions of the right hémi- 
sphère transformed in their surface into a sort of reddish bouillie ; in the substance 
also of this hémisphère, on a level with the centrum ovale of Vieussens, there were 
five or six points where the cérébral pulp was similarly softened. 

Thorax. — Heart large ; hypertrophy of its parietes and dilatation of its cavities. 



DISEASES OF THE ENCEPHALON. 



135 



Case 6. — Softening of a portion of the right hémisphère — No other symjytoms but 
permanent contraction of the left upper extremity — Pulmonary tubercles. 

A woman, seventy-eight years old, entered the La Pitié in a state of marasmus ; 
excessive diarrhœa, and a cough of long standing. She answered questions per- 
fectly well, but could not move at will either the upper or lower extremities of the 
left side. The fore-arm was flexed on the arm, and the hand formed an acute 
angle with the anterior surface of the fore-arm. The lower extremity, which was in 
a state of complète resolution, presented no appearance of flexion. She stated that 
about a fortnight before coming to hospital she was astonished to see the ring finger 
and little finger of the left hand suddenly flexed, without her being able to extend 
them again* After a few days the entire left hand became flexed on the fore-arm, 
and the latter soon after on the arm ; at the same time the lower extremity became 
numbed, heavier than the other, and at last became completely paralysed, but 
exhibited no signs of flexion. The patient always retained her consciousness, 
ne ver had any pain of head, nor of any part of the body. She had pulmonary 
phthisis ; at the summit of the right lung was an immense cavern. After remaining 
in the hospital about twenty days, she sank gradually, without exhibiting any new 
phenomenon on the part of the nervous System. 

Post moriem. A little below the circumvolutions, at the junction of the anterior 
and middle lobes of the right hémisphère, the nervous substance was manifestly 
softened ; no injection accompanied this softening ; the portion of brain softened 
resembled in colour and consistence a strong solution of starch in water. 

Remarks. — In this case flexion (contracture) was the only phenomenon caused 
by the softening. It was at first but partial, being limited to two fingers ; it then 
gradually increased, without, however, extending to the lower extremity, which 
presented nothing but simple paralysis. 

Case 7. — Softening affecting at the same time the optic thalamus and corpus striatum 
of one side — Flexion at the commencement, then resolution of the limbs — No other 
cérébral symptom — Aneunsm of the aorta. 

A man, fîfty-three years of âge, had been for a long time subject to rheumatic 
pains in différent articulations. Two years before entering the hospital, he began 
to feel violent beating of the heart, and his respiration became constrained and 
difficult. We soon recognised organic disease of the heart : ail along the sternum 
the bruit de soufflet was distinctly heard ; puise fréquent, small, and regular. 
After being twenty days in the hospital, he showed us one morning the right arm, 
which was strongly contracted : he stated that on awakening he was astonished to 
find himself unable to extend the hand on the fore-arm. The latter also was flexed 
on the arm, and the fingers being flexed on the palm of the hand, impressed on 
the skin the mark of the nails. The idea of softening of the brain occurred to us 
at the moment. He said he had never suffered any pain of head, dizziness, or 
disturbance of intellect. He was bled, and blisters to lower extremities. The 
flexion went ofF in the night, and on the folio wing morning we found the two 
extremities of the left side completely relaxed but paralysed. No change occurred 
on the part of the nervous System. The disease of the heart pursued its course, 
the limbs became infiltrated, ascites manifested itself, and the patient died sud- 
denly. 

Post mortem. Cranium. — The brain presented nothing remarkable till we got to 
the level of the optic thalamus and corpus striatum of the left side. Thèse two 
bodies were changed into a yellowish soft substance. The nervous substance 
around them was also softened. 

Thorax. — Hypertrophy of the parietes of both ventricles, with perceptible dimi- 
nution of the cavity of the left ventricle. From its origin, and as far as its entrance 
into the abdomen, the aorta was three times its natural breadth. Towards the 



136 



CLINIQUE MEDICALE. 



middle of the descending portion of the thoracic aorta, there was found a vast 
aneurismal pouch, winch opened into the posterior mediastinum. The latter was 
fiiled with large clots of blood. Thence the cause of the sudden death. 

Remarks This case differs from the two preceding in this, that the flexion of 

the limb was but temporary, and was soon replaced by simple paralysis. The 
latter continued till death, which was owing to the bursting of the aneurism of trie 
thoracic aorta. In this case also, as in the others, it is évident from the sudden 
appearance of the contraction, without any other nervous phenomenon preceding 
this lésion of motion, that the softening took place ail at once. This is the first 
case in which we see this altération seated in the optic thalamus and corpus 
striatum. 

Case 8. — Softening of the anterior and middle lobes of one of the hémisphères — Flexion 
at the commencement — Alternation of flexion and simple paralysis during the 
course of the disease — Chronic gastro-enteritis. 

A woman, thirty-seven years old, was subject from her youth to an almost 
constant diarrhœa. Digestion had been a long time laborious ; at intervais she 
coughed a little. When we first saw her, she was pale and emaciated. Two 
months before entering the hospital, a curious circumstance occurred to her : from 
time to time the little and ring fingers of the left hand were flexed with force, 
without the will of the patient being able to prevent it, towards the palm of the 
hand. This partial flexion lasted from about a quarter of an hour to two hours ; 
it then ceased. During the first month, it returned only every three or four days, 
no other nervous symptom accompanying it. At the beginning of the second 
month, ail the fingers became flexed, at intervais, on the palm of the hand, and 
soon after the hand itself was so flexed as to make an acute angle with the anterior 
surface of the fore-arm ; the hand also was so turned that its palm, instead of 
being on the same plane as the anterior surface of the fore-arm, looked outwards. 
This double flexion of the fingers, and hand from being but temporary, had become 
permanent, when we saw her. Hitherto the fore-arm itself was not afFected ; but 
we soon saw it flexed on the arm, at first temporarily, and then permanently. But 
what was remarkable, when the flexion of the fore-arm was well-established, that 
of the fingers dirninished, then ceased entirely, and at the same time that of the 
hand became less violent. For fifteen days the flexion of the fore-arm was con- 
stant ; then this also dirninished, and was finally replaced by simple paralysis. 
For a long time the latter existed in the left lower extremity. For eight days we 
observed nothing but hemiplegia, without any trace of contraction ; then the latter 
re-appeared. From thenceforward the upper extremity of the left side was 
observed to be alternately, sometimes in a state of complète resolution, sometimes 
in a state of flexion. This flexion affected either alternately or simultaneously, the 
fingers, the hand, the fore-arm. Three or four times the leg became violently 
flexed on the thigh. Sensibility retained in the extremities of the left side ; no 
pain, headach, or any disturbance in the intellect. The diarrhœa, however, became 
more severe ; a large eschar formed on the sacrum, and the patient died. 

Post mortem. Cranium. — Sub-arachnoid cellular tissue infiltrated with a little 
transparent sérum ; two spoonfuls of sérum in the latéral ventricles. The pos- 
terior and middle lobes of the right hémisphère changed, for two-thirds of their 
extent, into a yellowish bouillie, in which no vessel is observed, nor any sanguine- 
ous effusion. This softening commences about one inch below the circumvolutions 
of the convexity ; it extends nearly to the level of the optic thalamus, without 
involving that part : anteriorly it is terminated at the union of the two posterior 
thirds with the anterior third of the optic thalamus ; posteriorly it reaches nearly 
to the periphery of the brain. 

Thorax.— Some miliary tubercles, surrounded by healthy parenchyma, were 
scattered through the upper lobe of the left lung 



D1SEASES OP THE ENCEPHALON. 



137 



Abdomen. — Inner surface of stomach présentée! a slate-coloured tint in three- 
fourths of its exfent. The gastric mucous membrane exhibited considérable thick- 
ness, and its consistence was greater than natural. The villosities of the duodénum 
and of the commencement of the jéjunum presented a black tint. Numerous 
ulcérations, with black ground and raised edges, traversed the mucous membrane 
of the ileum ; some were also found in the cœcum, and at the commencement of 
the colon. Mesenteric ganglia large, and some contained tubercular matter. 
Liver pale, friable, and greases the scalpel. 

Remaries. — In the cases preceding this, we saw, fîrst, the flexion continue during 
the entire disease ; we then saw other cases, in which, only showing itself at the 
commencement, it was succeeded by simple paralysis. In the présent case, 
things are quite otherwise ; it is, again, by flexion that the lésion of motion exists ; 
paralysis succeeds it, then thèse two phenomena alternate. Another remarkable 
circumstance in this case is, that at first the flexion showed itself only at intervals, 
and between thèse intervais the extremities recovered perfectly their power of 
movement. In this case, also, as in ail those hitherto detailed, the principal or 
only seat of the flexion was the upper extremity ; the lower extrernity, however, 
participated in the lésion of motion, but frequently it was merely paralysed. 

Shall I now say one word regarding the chronic affection to which, for a long 
time back, the patient had been a prey ? This affection followed a course the 
inverse of its ordinary course. The digestive tube was first attacked, or at least 
it first manifested symptoms, and in the lung, on the contrary, the lésion seemed 
only to commence. With so few disturbances in the respiratory apparatus, the 
liver had, however, already undergone the fatty dégénérescence. 

Case 9. — Sqftening of the middle lobe of one of the hémisphères — Hemiplegia withoid 
complication of any flexion, 

A tailor, sixty-three years old, entered the hospital with jaundice and ascites, of 
which a liver disease seemed to us to be the cause; much emaciated. One day 
he complained of extraordinary weight and numbness in the upper and lower 
extremities of the left side. The hand of this side less able to grasp objects than 
usual. When he essayed to walk, he said he thought a weight of fifty pounds 
held his left foot to the ground ; no pain of head, dizziness, or sign of cérébral 
congestion. Ultimately hemiplegia of the left side. About two months after the 
paralysis appeared, diarrhœa set in, and the patient died, without having exhibited 
to the last moment any additional symptom on the side of the nervous System. 

Post mortem. Cranium. — A little below the centrum ovale of Vieussens, and at 
an almost equal distance from its anterior and posterior extremities, the right 
hémisphère présents a softening for a space capable of admitting a nut ; this 
softening is of a greyish white. 

Abdomen. — Yellowish sérum in the peritoneum ; cirrhosis of the liver ; mucous 
membrane of stomach marked with bright red dots towards its great cul de sac ; 
several of the intestinal follicles, and several points of the colon, very much 
injected. 

Remarks. — Here was a well marked case, in which there was no flexion of the 
limbs. The only phenomenon indicative of softening was paralysis, which was 
slowly established, as if a graduai compression was made on the brain. Thus, in 
référence to a lésion constantly identical in its nature and its seat, every case we 
détail présents to us différent functional disturbances. We shall see, in the follow- 
ing fact, paralysis again manifest itself without flexion, and, besides, présent at its 
commencement, and in its progress, circumstanees which will again exhibit to us 
under a new point of view the symptoms of softening of the brain. 



138 



CLINIQUE MEDICALE. 



Case 10. — Softening of one of the anterior lobes — At the commencement, signs uf 
cérébral congestion — Subsequently hemiplegia, which again disappeared — Bliridness 
on the side paralysed. 

A young nian, eighteen years old, of a strong constitution, began to expérience, 
at the commencement of the month of April, a pain of head, seated principally 
towards the forehead ; at the same time dizziness, vertigo, tinnitus aurium. With 
thèse signs of cérébral congestion, he entered the hospital the lOth of ApriL He 
stated the particulars of his own case with the greatest précision ; face red, and 
expressive of exhaustion ; no fever ; motion perfect, as was the cutaneous sensi- 
bility ; sensé of hearing impaired for the last three or four days ; twice already, in 
the course of the two preceding years, he experienced similar symptoms, aiways 
accompanied with some deafness (thirtyleechestothe neck ; purgative mixture, &c). 
In the course of the day, headach, vertigo, tinnitus aurium disappeared, as also the 
deafness, and on the following morning (12th of April) patient found himself very 
well. A little after the visit, he began to feel in the upper extremity of the left 
side a numbness, which went on increasing till night ; it was also weaker than the 
other ; he slept during the night, but, on awaking, the left upper extremity was 
entirely deprived of motion. On our visit of the 13th, we found this limb extended 
along the trunk, and entirely paralysed ; no sign of flexion ; sensibility of skin 01 
this limb still retained ; lower extremity of the same side still moveable. The 
right commissure slightly drawn up ; this déviation more évident when the patient 
smiles ; cannot see with the left eye ; the two pupils equally dilated ; puise had 
some frequency (bleeding to twelve ounces, sinapisms, purgative lavement). 
No évacuation from bowels. 

14th. Paralysis extended to the left lower extremity ; patient did not answer 
questions, except when strongly pressed (thirty leeches to neck, blisters to thighs, 
purgative mixture). 

lôth. Same state ; two stools after the lavement. 

From 16th to 25th. Hemiplegia still continued ; every morning we found the 
left upper eyebrow half depressed over the globe of the eye, and the right com- 
missure of the lips drawn upwards ; tongue, which was with difficulty protruded, 
deviated a little to the left. From this period to the Ist of May, the patient was 
twice bled, and leeches were frequently applied, as also sinapisms ; still his state was 
becoming worse, when, on the Ist of May, there was a visible amendment ; some 
movements began to take place in the parts paralysed. On the 4th, he could 
move the upper and lower extremities tolerably well ; lips and tongue no longer 
deviated ; left eye recovered its sight ; paralysis of the levator muscle of the left 
eyebrow ceased ; intelligence perfect; answers accurate ; puise no longer fréquent. 
In this state of things, we began to look forward to his recovery, and for the four 
days fullowing every thing seemed to confirai our hope ; but on the 8th, without 
any known cause, he raved in the night. On the 9th, we found him sunk in pro- 
found coma ; he spoke not ; evinced no pain on being pinched ; puise vcry 
fréquent (thirty leeches to neck) ; whilst the bîood was flowing. he emerged from 
the stupor, and returned to the state he was in on the precedÎDg days. From this 
period the movements of the limbs improved every day, except that he could not 
grasp any thing firmly in his left h and. Thus there remained but slight traces of 
the disease of the brain. But then new symptoms appeared ; the tongue became 
red and dry ; severe diarrhœa set in ; the skin of the great trochanter on the left 
side presented a livid red tint, announcing the approaching formation of an eschar. 
From this time puise became very fréquent and very small ; température of skin 
was raised, and a rapid wasting took place. He was again put on strict diet, 

24th. An enormous eschar formed on the great trochanter ; diarrhœa very 
abundant ; tongue very red, brown in the centre ; extrême debiiity ; intelligence 
still perfect ; no trace of the paralysis, but a certain weight in the left lower 



DISEASES OF THE ENCEPHALON. 



139 



extremity. Towards the end of May, a large ulcer formed in the externaî upper 
part of the left hand ; increasing debility. He died the commencement of June, 
without presenting any additional symptoms connected with the brain. 

Post mortem thirteen hours after death. General marasmus ; large ulcération on 
the left trochanter. 

Cranium. — Cérébral circumvolutions flattened on the upper surface of the 
anterior lobe of the right hémisphère, from the edge of this lobe to the corpus 
striatum. In this extent, the grey colour of the circumvolutions was replaced by 
a dirty white colour, shaded by a light rose tint. This portion, when touched, 
appears difîluent, and its extrême softness forms a striking contrast with the great 
consistence of the rest of the encephalon. This altération extended in height 
from the circumvolutions of the convexity, to those of the base. It occupied 
nearly ail the breadth of the anterior lobe. A reddish liquid filled the latéral 
ventricles so as to distend them. 

Thorax. — Nothing particular. 

Abdomen. — Stomach distended with gas and liquids ; its inner surface presented 
a bright redness in several points of its extent. Duodénum white in the flrst 
portion. In the second and beginning of third, its mucous membrane marked by 
a number of red points crowded together. The inner surface of the caecum, 
ascending colon, and a great part of the transverse colon, presented an intense red 
appearance, arranged in numerous patches. Where thèse patches existed the 
mucous membrane was softened. 

Remarks. — The symptoms of cérébral congestion presented by this individual 
on his admission, are such as are frequently met with, and they ordinarily yield to 
blood-letting, and other antiphlogistic means. Here they were the precursors of 
a much more serious affection ; hemiplegia complicated them, or rather succeeded 
them, for it is remarkable, that from the moment the extremities of the left side 
began to move less easily, the signs of cérébral congestion disappeared ; even the 
deafness ceased. The left side of the face and eye-brow were also affected ; the 
tongue also deviated to the left. In none of the parts paralysed was there any 
flexion observed. Nearly at the same time the sight of the left eye went. In the 
midst of thèse disturbances intelligence remained intact, and even at a later period 
it was only affected at intervais. Coma often appeared, which went away the 
next day ; thus, the only constant functional disturbance was that of motion ; for 
the amaurosis of the left side was also but temporary. At last a period arrived 
when motion itself was so far restored, that there were no longer any traces of 
paralysis, and the cérébral affection seemed cured. It was then that new pheno- 
mena appeared connected with the enormous eschar on one of the trochanters, and 
with the gastro-intestinal inflammation which arose. It was of thèse the patient 
died. Should we expect to find any lésion in the brain ? We could scarcely 
think so, since the symptoms of this lésion had for a long time ceased to exist. 
Some days before death there was nothing but that gênerai debility of motion, 
sensation, and intelligence, characterising the adynamic state, and which is not 
connected with any spécifie altération of the encephalon and its appendages. 
However, a very serious lésion still existed in the brain ; it continued still very 
intense in the absence of the symptoms to which it first gave rise. 

This lésion was precisely limited to one of the anterior lobes, and yet the upper 
extremity had been paralysed ; it extended to the circumvolutions, and yet the 
disturbance of the intelligence was but a secondary and a transitory phenomenon. 
In fine, speech was still retained though the softening was seated in the anterior 
lobe. 

Case 11. — Softening of one of the hémisphères— Injection of the other — Convulsive 
movements — State qf coma on the last day. 
A woman, aged twenty-seven years, after having exercised very much through 
Paris during the month of July, was seized with dizziness and pain of head, prin- 



140 



CLINIQUE MÉDICAI E. 



cipally seated in front ; had no sleep nor appetite for food. Thèse symptorns of 
lassitude, with tendency to cérébral congestion, existed for ten days, when the 
patient was subniitted to our examination. Pain of head still continued, occupying 
only the front of head, and particularly the two supra-orbital régions. Patient had 
vertigo ; felt carotids beat strongly ; face red and swollen ; a sort of numbness of 
the limbs ; puise fréquent ; skin hot ; tongue foui (she was instantly bled). Xext 
day, state nearly the same (thirty leeches to anus). From thirteen to fourteen 
days elapsed from the commencement of the attack, when she was seized suddenly 
with violent convulsions of the left upper extremity, which returned from seven to 
eight times during the first twenty-four hours of their appearance, and lasted each 
time about twenty minutes. During the intervais tbe limb enjoyed ail its power 
of moving ; the Angers were occasionally observed to be moved convulsively (bled 
again, and sinapisms applied to the lower extremities). In a day or two the right 
side of the face also became the seat of convulsions. In the midst of ail this dis- 
turbance of motion, intelligence and sensation were, as yet, intact ; but the matter 
was soon changed. Twenty-four hours after, the convulsive lits became more 
fréquent ; affected the entire body ; took possession, either successively or 
simultaneously, of both sides of the face, right and left extremities ; they were 
A.'^ays more intense in the upper extremities than in the lower ; the first signs of 
ïerebral congestion now became more intense, in proportion as the fits became 
more fréquent ; face very much injected ; intellect at first struck with stupor, 
became at last extinct ; then coma set in ; the convulsions ceased ; respiration 
became embarrassed, and the patient died in a state of asphyxia. 

Post mortem. The sub-arachnoid cellular tissue of the convexity of the hémi- 
sphères infiltrated with a slightly turbid sérum ; circumvolutions not changed either 
in colour or consistence ; about two inches below the bottom of the anfrac- 
tuosities, towaTds the centre of the space extending between the extremity of the 
anterior lobe of the right hémisphère and the corpus striatum of the same side. 
and not far from the interlobular fissure, the cérébral pulp is sensibly softened. 
and this softened part is of a deep red ; this softening may occupy about a cubic 
inch ; around it the cérébral substance considerably injected ; in the anterior lobe 
of the left hémisphère, nearly in the same place, there was observed such an 
injection of the brain that its substance appeared as it were ecchymosed ; the 
consistence of this part natural. 

Remarhs. — We do not think the symptoms of cérébral congestion in this 
case depended on the softening which we afterwards detected. This softening 
was formed subsequently, and at first there was probably but a greater afflux of 
blood than natural in the cérébral vessels. We may observe, besides, what little 
influence the bleeding exercised on the symptoms by which the cérébral hyperemia 
evinced its existence, and consequently on the hyperemia itself. The latter was 
in some measure the precursor of the more serious lésion, which succeeded it after 
the lapse of twelve days, and with which the appearance of the convulsive niove- 
ments was connected. Here then the softening announced itself in a manner 
altogether différent from the preceding cases : the prominent functional disturb- 
ance still affected motion, but this disturbance was quite of another kind ; it is no 
longer flexion, as in several cases — no longer paralysis, as in others. The con- 
vulsions were first confmed to the left side, and it was in the right hémisphère that 
the softening was fouud. Subsequently the right side of the body became con- 
vulsed in its turn, and there was found in the left hémisphère a lésion less 
advanced than that of the right hémisphère, which seems to be a first degree of 
it. Observe, accordingly, that the softening here has a well-marked red colour, 
and that around it there was considérable injection of the nervous pulp. One 
would be disposed then to admit that this redness and injection preceded the 
softening ; if life had been prolonged, it is extremely probable that the ecchy- 
mosed portion of the left hémisphère would bave lost its consistence. Besides, 



DTSEASES OF THE ENCEPHALON. 



141 



Ihe symptoms support this mode of viewing the matter. They were observed to 
be the same on both sides of the body ; and still more, the side of the body iast 
convulsed was opposite to the side of the brain where we found the lésion, which 
we consider as the one less advanced, and as the first degree of the other. The 
state of coma observed on the last day is only the state in which most persons 
die who have been subject to convulsions more or less prolonged. But so far the 
disturbance of motion had not in the slightest degree involved that of the intel- 
ligence. Observe also, that the double lésion of the brain was seated on each 
side in the same point ; that this lésion, as in the subject of the ninth case, again 
resided in the most anterior part of the hémisphères, anterior to the corpora 
striata, and that notwithstanding the altération of motion commenced and always 
predominated in the upper extremities. Neither was there loss of speech ; for up 
to the appearance of the comatose state, the patient constantly explained how she 
felt without evincing any dirnculty of articulation. 

Case 13. — Softening in the two hémisphères — Paralysis of long standing; sùbse- 
quently tétanie rigidity of one of the arms produced by a new softening — Dehrium 
towards the end. 

A man, fifty-five years old, entered the La Charité with hemiplegia of the right 
side. We learned from him that he had lost by degrees the motion of the right 
side, without having ever had either contractions or convulsions ; though he ex- 
plained his state very well, and evinced no aberration of intellect, still there was 
a vagueness in his answers which denoted a degree of mental debility. At the 
end of three months, his state became suddenly changed ; the habituai torpor in 
which he had been frequently plunged was succeeded by a gênerai state of 
agitation ; he was quite delirious ; extremities of the right side immoveable and 
flaccid as usual ; those of the left side presented new phenomena — thus the 
upper extremity, which was no longer capable of voluntary motion, was extended 
along the trunk. and presented a rigidity like to that of tetanus ; it was not 
flexion (contracture) ; the patient, by a sort of automatic motion, constantly threw 
off his bed-clothes with his left leg. The next day we no longer found any trace 
of the excitement of the preceding day. The delirium was replaced by a duiness 
of intellect ; the left extremities w r ere paralysed as those of the right side ; the 
flve following days the features became altered ; the face was yellow ; tongue 
dry ; puise very fréquent ; abdomen tympanitic ; severe diarrhœa set in, and the 
patient died. 

Post mortem. Pia mater injected over the entire conrexity of the hémisphères ; 
the nervous substance, very firm except in one point-, which we shall mention, 
was as it were sanded (sablée) with a great number of red points. At the anterior 
and inner extremity of the left hémisphère, the latter appeared as if depressed, 
and gave to the finger the sensation of the parietes of an empty cavity ; the 
arachnoid covering this portion of the brain was of an intense red eolour ; beneath 
it the cérébral substance was reduced into a bouillie of a rose-white eolour ; this 
softening extended posteriorly as far as the corpus striatum, the most posterior 
part of which it hardly reached ; it penetrated in depth to a little above the level 
of the centrum ovale ; it occupied a breadth of three inches. In this same left 
hémisphère, exterior and a little anterior to the optic thalamus, and on a level 
with it, there existed to the extent of two inches in every direction, a second 
softening, of a chocolaté eolour. 

In the right hémisphère, the corpus striatum presented to us in its middle part 
a third softening, of a yellow reddish eolour ; it was limited exactly to the central 
part of this body, which, around it, had preserved its usual eolour. 

Remarks. — The double softening of which the left hémisphère was here the 
seat, gave rise to no other phenomena than to a progressive diminution of motion 
in the right extremities, and ultimately to their complète paralysis. In this case, 
nevertheless, there was not more intellectual torpor than in the preceding cases. 



142 



CLINIQUE MEDICALE. 



Though this softening, existing in two différent points, had occupied rather an ex- 
tensive portion of the left hémisphère, the disease followed a course altogether 
chronic ; the softening of the right hémisphère, on the contrary, though far less 
considérable, produced more acute symptoms. It is on it that the tétanie rigidity 
of the right arm depended, which we have not y et noticed in any of our cases, and 
wldch must not be confounded with flexion (contracture) ; this is also the first 
time we see delirium appear ; but in this case was it not ovdng to the manifest 
hyperemia of which the méninges were the seat ? This case resembles the pre- 
ceding in the nature of the softening, which, wherever it existed, was coloured 
with différent red shades. 

With respect to the softening, here again, as in several of our cases, it was no t 
mdicated by the seat of the lésion of motion : in the left hémisphère, to be sure, 
there was double softening, one in the anterior lobe, the other in the middle lobe, 
and the two extremities of the right side were paralysed ; but in the right hémi- 
sphère, the middle part of the corpus striatum is the only part altered, and yet the 
left upper extremity présents in its movements a disturbance which eau only be 
explained by this lésion ; the lower extremity, on the contrary, manifested neither 
paralysis, nor flexion, nor convulsion, nor tétanie rigidity. 

Case 13. — Softening of the optic thalamus of the right side — Diffiuent state ofthe 
fornix — Tétanie phenomena at first — Subsequently alternations of paralysis 
and convulsive movements on the left side ofthe body. 
A pavior, thirty years of âge, strong constitution, experienced on a sudden, 
without any known cause, a rigidity of the nape of the neck ; rétroversion of the 
head ; trunk soon after inclined in the same direction. On entering the hospital, 
after a lapse of six days, his state was as follows : — Strong rétroversion of the head ; 
patient could neither move it forwards, nor incline it to either side ; trunk arched, 
so that the middle of the back no longer rested on the bed ; acute pains in the 
back of the neck, which were not increased on pressure ; the jaws presented the 
commencement of trismus. No other functional disturbance. (Patient was bled 
from the arm ; two days after, thirty leeches to anus.) Some days now elapsed, 
and no change ; rétroversion of the head continued, as well as the incomplète 
trismus already noticed ; but further, the muscles of the extremities and of the 
abdominal parietes presented a commencement of rigidity. The patient said he 
felt some uneasiness in the arms. Thus tetauus, at finit partial, was now become 
gênerai, and already lasted for fifteen days. (He was bled again.) The following 
day, the disease presented another aspect. The rétroversion of the head con- 
tinued, but it was at the same time inclined to the left ; the rigidity of the abdo- 
minal parietes and that of the extremities disappeared ; but the left upper 
extremity had lost ail the power of motion ; when raised, it fell back, as an inert 
mass ; the skin of it, when severely pinched, gave the patient no pain ; he had his 
eyes shut, and seemed asleep ; but we could, by speaking to him, arouse him from 
this stupor, and then his answers were accurate ; he could not tell us at what 
period his left arm became paralysed ; he said he did not recollect ; and he 
was very much astonished at not being able to move it ; he said he no longer felt 
it. Puise acquired a slight frequency. Fifteen leeches were applied across each 
jugular vein, and a blister to each leg ; during the day, and whilst the leech-bites 
were bleeding, the paralysed limb was seized with convulsive movements. On 
the next morning, we found the stupor still more profound ; pupils very much 
dilated ; they contracted, however, at. the light. No appearance of convulsion 
during the visit ; the paralysis of the left arm seemed as marked as on the pre- 
ceding day ; puise fréquent ; respiration accelerated. A little time after we left 
the patient, the convulsions reappeared, but this time they were not confined to 
the paralysed limb ; the face and both sides of the body were several times 
affected with thern. 



DISEASES OF THE ENCEPHALON. 



143 



The two following days, no convulsions; left arm remained constantly in a state 
of simple resolution ; the other limbs moved at the will of the patient ; he was 
in a constant stupor ; when spoken to, he opened his eyes, strove to answer, 
but could not articulate ; puise very fréquent and veiy small ; pupils very 
much dilated, still they contracted under the impression of light. Next day, the 
scène changed ; great agitation ; continuai screams ; face covered with sweat. 
In the course of the day, violent convulsions, extending to ail the body, in the 
midst of which the patient died. 

Post mortem. Pia mater surrounding brain both at the convexity and at the 
base, very much injected ; the superficial grey substance of the circumvolution 
participâtes in this injection ; the latéral ventricles filled with limpid sérum in such 
a quantity as to distend them ; the posterior part of the fornix changed into a dull 
white diffluent bouillie ; the right optic thalamus, in its middle part, présents a 
softening as perfect as that of the fornix ; it difFers, however, in this, that it 
présents a reddish tint ; near its periphery this ganglion resumed ail its con- 
sistence. 

Remarks. — Three periods may be distinguished, with respect to the symptoms, 
in the disease which forms the subject of the preceding case. First period was 
marked by phenomena resembling those of tetanus ; with thèse the disease com- 
mencée!, ïn the second, the tétanie phenomena disappeared, and nothing was 
observed but simple paralysis, limited to one of the upper extremities. In the 
third period, in âne, this paralysis alternated with convulsive movements, which 
developing themselves only in the part deprived of motion, then extend to the 
entire body. Intelligence free during the first period. In the second and third 
periods, a stupor was observed, which at first did not prevent the patient from 
answering distinctly the questions put to him. At a subséquent period this stupor 
became more profound, and ultimately was replaced by a convulsive agitation, in 
which the patient died. 

To explain thèse complex symptoms, we find lésions equaliy complex, whose 
précise part in causing the symptoms it is rather difficult to assign. And first, it 
may be asked, if, in the first period, at the time when nothing was yet observed 
but symptoms of tetanus, the right optic thalamus was already softened. Did 
thèse symptoms dépend rather on an affection of the méninges ? But then there 
would have been some disturbance in the intelligence. Now, that did not take 
place. Thus we are inclined to think, that the bright red injections of the pia 
mater, and of the circumvolutions, ascertained by the post mortem, were formed 
only in the third period, at the time the intelligence became disturbed. Did those 
symptoms of tetanus dépend rather on the softening of the fornix ? The only 
answer we can give to this is, that we have frequentiy found on the dead body a 
similar softening, without anything similar having take n place during life. In no 
case have we seen softening of the fornix, whether partial or gênerai, produce any 
cérébral symptoms whatever. We cannot, then, assert positively that the lésion 
which produced the tétanie symptoms was of the number of those revealed by 
the post mortem. Perhaps the softening of the right optic thalamus took place 
during the morbid process which produced the tetanus. The phenomenon which 
no doub.t depended on it, the paralysis of the left arm, showed itself only at the 
same time that the tétanie phenomena ceased. With respect to the convulsions, 
it is probable that they depended on the affection of the membranes, and of that 
of the grey substance subjacent to them. The partial convulsive movements 
which opened the scène, and which occurred in the paralysed limb, might alone 
have been referred to the softening of the optic thalamus. It is probable that the 
great distension of the ventricles by sérum performed a part in the production of 
the stupor. This case, contrary to several of the preceding, might be urged in 
favour of those who place the source of the movements of the upper extremities in 
the optic thalami. 



144 



CLINIQUE MEDICALE. 



CHAPTER IIL 

CASES WHEREIN, WITH DIEFERENT LESIONS OF MOTION; THE RE EXISTED A 
LESION OF SENSIBILITY. 

According to some of those who hâve written on softening of the brain, pain 
of head is one of the most constant symptoms, and it marks partîcularly the com- 
mencement of the affection. The examples already quoted prove at least that, in 
a considérable number of cases, this symptom may be wanting. We shall now see 
a case where pain of head was a prédominant symptom. 

But it is not merely by pain of head that softening may announce itself. There 
are cases also where, whether this headach exists or not, the patients feel in 
différent parts of the body, and particularly in the extremities, acute pains, some- 
times continued, sometimes intermittent, which précède the other symptoms, or 
complicate them. Thèse pains might occasionally impose on one for rheumatic 
pains. It is then very important to be at least apprised of the possibility of their 
existence. 

Case 14. — Softening of the right hémisphère — Hemorrhage into the other hémisphère — 
Pain ofhead, with commencing paralysis of the Umbs ofthe leftside — Subsequently, 
violent attack of apoplexy. 

A woman, fîfty-three years of âge, had always enjoyed good health. In the 
month of September, 1831, she began to feel, at the junction of the temporal and 
pariétal régions of the right side, a pain which was at flrst dull, and existed only 
at intervais. At the end of a fortnight, the pain became more acute ; every two 
or three days it was suddenly aggravated. After remaining thus from seven to 
eight minutes, it diminished, stiïl acute enough to prevent her from her usual 
employment. She then applied to a physician, who bled her ; pain was not 
diminished. Two or three days after, she perceived that she couid not hold 
objects as well with her left as with her right hand. She then entered the hospital 
La Fitié. At this time she had had the pain of head about twenty-five days ; 
intellects perfect. From the nature of her headach, we would have employed 
sulphate of quinine, combined with opium, suspecting it to be nervous, did there 
not exist in the left extremities phenomena which seemed to indicate compression 
or disorganisation in some part of the right cérébral hémisphère. Thèse phenomena 
were the folio wing : — The patient lelt in thèse limbs, for the last few days, a 
degree of debility, which continued to increase. She could, however, move them, 
but with more difficulty ; and when she tried to walk, she fancied her left leg was 
about to be withdrawn from under her. The pulp of the fingers of the left hand 
were the constant seat of troublesome formication ; sensibility of skin naturaî. 
She was bled again, without any efFect of any kind. Twenty leeches were applied 
twice to the anus, and a large blister to the nape of the neck. One day 
whilst walking in the ward, she fell down, deprived of consciousness and motion. 
On the following morning we found her in the state of one who had been just 
struck with apoplexy. She died in the evening. 

Post mortem. Méninges very much injected ; sanguineous suffusion in the pia 
mater covering the left hémisphère. On removing some slices from the left hémi- 
sphère, the scalpel fell into a large cavity filled with black blood, haviny the con- 
sistence of currant jeîly. It occupied at least one third of the hémisphère ; the 
optic thalamus and corpus striatum were affected, and the blood burst into the left 
ventricle ; the septum was not injured. The right hémisphère presented quiie a 



DISEASES OF TKE ENOEPHALON. 



145 



différent' appearance ; externally it appeared healthy, as the left ; but at^two 
inches depth it began to lose its consistence ; at first, a little softer than at its 
periphery, it was changed a little lower down into a bouillie of a dirty grey colour, 
traversed by some vessels, without any of the blood in them having spread. 
This softening terminated anteriorly towards the anterior part of the corpus 
striatura, and behind, extended a little beyondthe posterior extremity of thisbody. 
It terminated inferiorly towards the level of the corpus striatum, being situated 
more externally than it, and it left it completely intact. 

Remarks. — If in the 13th case we were puzzled in Connecting the several 
lésions with the symptoms, such is not the case here, where every thing is 
plain and manifest. The pain of head and commencement of paralysis of the 
left extremities are explained by the softening in the right hémisphère. The, 
copious hemorrhage of the other hémisphère accounts for the phenomena 
observed towards the close. But why this remarkable pain of head in this 
case, which was wanting in the other cases cited ? Pathological anatomy no 
longer explains thèse différences ; the lésion found has the same seat, and, as 
far at least as we can judge, is of the same nature. See, besides, how long 
a time this pain of head remained the only phenomenon : how long a time 
also it seemed to be but one of those simple nervous pains, which disappear 
as they come, without leaving behind them any trace of their existence. In 
what state was thë brain, as long as the headach existed alone ? What new 
lésion came to complicate the change which had produced the headach, when 
the latter began to become complicated with an altération of motion ? Thèse 
are very interesting questions, which we are as yet unable to solve, the solution 
of which, however, may be conceived to be possible by the aid of patient 
investigations. 

Case 15. — Softening of the right cérébral hémisphère — Acute pains in the left 
extremities, which subsequently became paralysed, still continuing painful. 

A woman, seventy-one years old, had felt, for about a year before entering 
the hospital, acute pains in the two extremities of the left side. Thèse, which 
were at first transient, became lancinating, occupying particularly the anterior 
surface of the upper extremity, and the posterior surface of the lower extremity. 
When they were very intense, they gave rise occasionally to slight convulsive 
twitches of the Angers, and particularly of the index finger. Occasionally too, 
but only after, or during a pain, the thumb was flexed on the palm of the hand, 
this flexion never lasting beyond ten or twelve minutes. This was the first 
time the patient experienced such pains ; by degrees they became more fré- 
quent, and at last continued ; but at the same time they abated of their original 
severity, and ultimately the patient only felt in the extremities oi the left side, 
and particularly in the upper, a sensation of formication. She continued thus 
for five months ; she then ceased to be able to sustain herself on her left 
leg as well as before : this limb seemed to her dull and heavy, and she dragged it 
a little in walking. At this time also the left upper extremity became weaker ; 
she could no longer grasp, or hold any weighty object with the hand of this 
side. By degrees, this paralysis increased ; and at the end of six weeks, it 
was as complète as possible. But, what was extraordinary, from the time the 
muscles of the extremities of the left side were entirely deprived of voluntary 
motion, the pains which had marked the commencement of the disease returned 
with their original severity, and from time to time they increased so as to 
make her shed tears. This was the state she was in when she was submitted 
to our inspection. She was at this time emaciated and pale, eyes sunk, features 
drawn and expressive of long suffering. Every two or three days, the extremi- 
ties were as it were furrowed by acute pains. The skin of thèse parts much 

L 



146 



CLINIQUE MÉDICALE. 



more insensible than those of the limbs of the right side. Power of motion 
eompletely destroyed in them ; right commissure of lips drawn up ; tongue 
deviated visibly to the left ; skin of face on right side less sensible than on 
left ; the intelligence perfect. She told us that from her nineteenth to her 
twenty-third year, she had been tormented with violent beating of the heart 
accompanied with great difficulty of breathing. Thèse symptoms, however, 
eompletely disappeared. After remaining about a month in hospital, a large 
eschar formed on the sacrum, she gradually wasted away, her feet became 
œdematous, and she sank exhausted, retaining her intellect to the last. 

Post mortem. On a level with, and external to t'he optic thalamus and corpus 
striatum of the right side, we found considérable softening of the cérébral sub- 
stance, which extended to the base of the brain. Anteriorly, it was limited by a 
line, the internai extremity of which might terminate at the junction of the anterior 
four-fifths with the posterior fifth of the corpus striatum. Posteriorly it extended 
nearly to the posterior extremity of the hémisphère. No injection in the softened 
portion. The softened cérébral substance is of a greyish white in certain points, 
and yellowish in others, The fornix and septum lucidum diffluent. The two 
latéral ventricles distended with sérum. The great arteries of the brain ossified. 
Heart and lungs healthy ; some ossifications in the aortic valves. The gastric 
mucous membrane visibly softened towards the great cul de sac in several points. 

Remarks. — There have been recently mentioned some cases of neuralgiae of the 
trunk and extremities, connected with altérations of the spinal marrow appréciable 
by anatomy. In the above case, might not one also have taken for simple neuralgic 
affections those pains which, on the left, occupied principally the trajet of the great 
nervous cords, and which, for several months, were the only morbid phenomenon ? 
Observe, also, that like ail purely nervous pains, they first assumed an intermittent 
form. Far from ceasing, they re-appeared with new intensity, when the limbs in 
which they were seated began to be paralysed. And what is truly singular, at 
the very time when they were most acute, the skin felt but in a very dull manner 
the impression of external bodies. Thus the sensibility, exalted in the deep-seated 
parts of the limbs, was extinct at their circumference. 

Case 16. — Softening of the anterior extremity of one of the hémisphères— At the 
commencement, headach, and acute pains in différent parts of the hody — Subse- 
quently flexion and hemiplegia — Death by supervening pneumonia. 
A female, nineteen years of âge, seven months before entering the hospital, felt 
a dull pain in the right temple, w r hich becoming worse from time to time, then 
became gênerai, and was accompanied with great dépression ; it often, when very 
acute, extended to the nape of the neck, thence descended towards the left side of 
the neck, and involved the entire left upper extremity, extending occasionally to 
the left lower extremity. Thèse pains were very changeable in character ; some- 
times she felt as if needles were in her ; sometimes as if subjected to very intense 
heat ; pressing the muscles, also, sometimes gave pain ; the skin of the left extre- 
mities sometimes, too, became painful. Such were the affections of the sensibility, 
when, in its turn, the power of motion also became affected ; the fingers became 
flexed on the hand, the hand on the fore-arm, and the latter on the arm. The left 
lower extremity soon participated in this flexion. From the moment the latter 
supervened, the pains assumed increased intensity. In this state we saw the 
patient. She then complained of cruel pains in the two extremities ; flexion was 
at its very highest degree. Headach continued, but less acute. (A seton was 
put in the nape of the neck, the flexed limbs rubbed with anodyne liniment.) 
From fifteen to twenty days passed on without any change ; she then exhibited 
the following modification in her condition : — Pain of head now changed into a 
sensation of weight in ail the left side of the head ; extremities no longer painful ; 
the skin covering them now insensible ; fingers and toes benumbed and cold ; the 



DISEASES OP THE ENCEPHALON. 



147 



flexion was now gone, and was replaced by the mere abolition of motion in the 
left extremities ; the left side of the face participated in this paralysis, and the 
right commissure of the lips was drawn up. Whilst in this state, the patient was 
attacked with pl'euro-pneumonia, of which she died. 

Post mortem. The entire anterior lobe of the right hémisphère changed into a 
greyish bouillie. The corpus striatum and anterior portion of the optic thalamus 
participate in this change, which did not, however, extend to the circumvolutions 
of the convexity, nor those of the base. Thèse circumvolutions were merely 
flattened. A mixture of red and grey hepatisation of the inferior lobe of the left 
lung. 

Remarks. — Three periods marked the course of this disease. In the first, the 
whole disturbance regarded the sensibility ; acute pains occupy, simultaneously or 
alternately, first the head, then the nape of the neck, then the limbs opposite the 
side of the head affected. Thèse pains are remarkable both for their intensity 
and for their character : one might take them for mere nervous pains. After 
several months cornes another period, during which disturbance of motion is added 
to that of sensation ; the painful limbs become the seat of slight convulsions, 
which are soon succeeded by strong flexion. From that time the nature of the 
disease became more évident ; but in its successive phases it was not to rest there, 
and, at the end of a certain time, it entered in some measure into a third period, 
during which simple paralysis replaced the flexion of the limbs. Then the pains 
cease, and the sensibility of the skin, recently so much exalted, is itself destroyed. 
Ail this succession of phenomena takes place during a space of from eight to nine 
months, and the cérébral disease did not yet finish its course, when pneumonia 
carried off the patient. Amidst ail thèse disturbances of sensation and motion, 
the intelligence remains intact ; towards the end only a difficulty of speech super- 
vened, which was this time connected with the seat of the lésion in one of the 
anterior lobes. Observe, besides, that the circumvolutions did not participate in 
the softening ; and do not overlook this circ.umstance in a case where the intel- 
lectual faculties were preserved so entire, notwithstanding the great extent of the 
lésion. Remark, also, that in this case, where the change of motion affected the 
two extremities, the optic thalamus participated a little in the very complète 
softening of the portion of hémisphère placed before it. 

Thus pains in the limbs, accompanied or not with headach, may exist for a long 
time, at least, as the only symptom of softening of the brain. In the face of thèse 
facts, what becomes of the hypothesis, which laid it down, that the altérations of 
the sensibility denoted an affection of the cerebellum '? It was also asserted, that 
diseases of the brain, like to those of the lungs, were not accompanied with pain, 
unless the serous membranes covering them were also affected. Now, in the 
cases just detailed, the membranes remained perfectly intact, and still there was 
pain. No inference is to be drawn for pathological purposes, from those fre- 
quently quoted experiments, in which, on cutting the cérébral substance in dif- 
férent directions, no appearance of pain was evînced by the animais. 



x 2 



148 



CLINIQUE MEDICALE. 



CHAPTER IV. 

CASES IN WHICH THE LOSS OF SPEECH WAS THE ONLY SYMPTOM, OR ONF OI THE 
PREDOMINANT SYMPTOMS. 

Case 17. — Softening of the two hémisphères — Loss of speech, tvithout lésions oj 
intelligence, motion, or sensation. 

This was the case of a woman, eighty years old, who, three years before entering 
the hospital, was suddenly deprived of speech ; never had loss of consciousness ; 
motion and sensation of the four extremities in the normal state ; the sensés ot 
hearing, sight, and smell natural. She presented the signs of organic disease of 
the heart. After entering the hospital she daily became more débilita ted ; respir- 
ation more embarrassed ; the trachéal râle set in, and she died at last of pulmonary 
disease. 

Post mortem. Craninm — \st, Left hémisphère. — On a level with, and external to, 
the posterior extremity of the corpus striatum, entirely at its apex, there is a 
softening of the cérébral substance : the portion softened is of a greyish colour. 

2tid. Right hémisphère. — At the junction of the anterior and posterior half of this 
hémisphère, at an equal distance from its internai and external edges, and at the 
point of junction of the two upper thirds with the lower third of the nervous mass, 
situated above the centrum ovale of Vieussens, there is a softening similar in every 
respect to that of the opposite side. Small serous cysts scattered in great 
numbers through the choroid plexus. 

Thorax. — Heart large ; parietes of the left ventricle very thick ; the right and 
left cavities filled with black blood, which has the consistence of currant jelly. 
Bony incrustations in the aortic valves, and over the entire extent of the aorta ; 
large quantity of sérum in pericardium and right pleura ; the right lung présents, 
towards the inferior part of its upper lobe, a portion of its tissue, the size of an 
orange, exhibiting ail the characters of pulmonary apoplexy. 

Remarks. — This case is well adapted to invalidate certain opinions published in 
later times. Thus, the only cérébral phenomenon which existed was loss of 
speech, and the only lésion of the brain discovered was not seated in any of the 
points of the encephalon, to which the faculty of speech has been assigned. 

Case 18. — Softening of the left corpus striatum — Loss qf speech — Hemiplegia— Pré- 
servation of the intelligence. 

A woman, seventy-three years old, had enjoyed good health, in particular never 
complained of headach, when suddenly, without loss of consciousness, she felt her 
right leg become flexed under her, and she fell. On being taken up, she was 
found paralysed on the right side. Two days after she was brought to the La 
Pitié : the two extremities of right side deprived of motion ; patient cannot speak; 
intelligence perfect ; when asked whether she has pains, she puts her hand to the 
right side of the face ; tongue inclines to the right. After having been bled 
twice without any benefit, and signs of pulmonary engorgement coming on, she 
died in a state of asphyxia. 

Post mortem. On the right and near the great interlobular fissure, a fîbrous 
body, the size of a hazel-nut, was imbedded in the dura mater. The large veins 
passing between the circumvolutions gorged with blood ; pia mater injected. The 
only altération in the encephalon is in the corpus strratum of the left side, which 
has lost its natural consistence. 

Remarks. — The seat of the softening here is worthy of remark ; it is exactly 
limited to one of the corpora striata, which does not prevent both extremities from 
being paralysed, together with loss of speech. 



DISEASES OF TRE ENCEPHALON. 



s 49 



CHAPTER V. 

CASES IN WHICH, WITH DIVERS DISTURBANCES OF MOTION AND SENSATION, THERE 
WAS DISTURBANCE OF THE INTELLIGENCE. 

The cases next to be considered are naturally divided into two groups ; in the 
first we shall find cases, where the intelligence is entirely destroyed in a manner 
quite instantaneous. The patients deprived of consciousness are plunged into a 
state of coma more or less profound. In such cases, the softening of the brain 
bears the greatest resemblance to hemorrhage of this organ. A second group 
présents us cases altogether différent : namely, — of individuals, in whom the coma, 
when it does exist, cornes on but gradually ; their intelligence is not suddenly 
destroyed, as in the preceding class, but it is perverted, or merely weakened, and 
they présent, as a prevailing phenomenon, a delirium variable in its intensity and 
its forms. In cases of this kind, softening of the brain differs very widely in its 
symptoms from hemorrhage, and on the contrary, it approximates, in certain 
respects, to some forms of inflammation of the méninges. 



ARTICLE I. 

SOFTENING OF THE BRAIN, WITH COMPLETE AND SUDDEN LOSS OF CONSCIOUSNESS. 

Case 19. — Weakness of the right extremities of an old standing — Suddenly a fall witJi 
loss of consciousness — Coma — Softening of one entire hémisphère. 

A man, forty-seven years old, felt, for the last two years, a pain in the left side 
of the head, and since about the same period, the extremities of the right side 
were weaker than those of the left. Suddenly, after complaining of his head more 
than usual, he fell to the ground, deprived of consciousness. After two days he 
was brought to the La Charité, where he presented the following state : — Profound 
coma ; respiration stertorous ; sensé of hearing seemed gone ; on raising lids, 
globe of the eye fixed ; pupils contracted ; sensibility of conjunctiva seemed 
gone ; face very red, and as if swollen ; mouth deviated to left side ; four extremi- 
ties relaxed ; when raised they fell back as inert masses ; sensibility seemed quite 
abolished ; puise very small, not fréquent (bleeding-, blisters to legs). He died 
the next day. 

Post mortem. Cranium.—k. striking différence in the size of the two hémisphères, 
that of the left side occupied much more space than the other, so that the great 
interlobular fissure was no longer on the médian line, but was thrown to the right 
of this line ; the eircumvolutions of the convexity of the left hémisphère flattened. 
A very little distance beneath them the cérébral substance became extremeîy soft ; 
a iittle lower still it was converted into a greyish bouillie. The same state of 
difïluence was observed in ail the rest of the hémisphère, nearly to its base. In 
ail this softened mass no effusion of blood ; it was crossed in différent directions 
by vessels, whose parietes retained their natural consistence. 

Thorax.— Great infarction of the lungs ; heart very large; hypertrophy of its 
parietes ; contraction of the aortic orifice ; its valves as it were soldered together. 

Abdomen. — Liver gorged with blood ; injection of the gastro-intestinal mem- 
brane. 

Remarks.~ln none of the preceding cases have we seen such extensive softening'. 
Here the intensity of the lésion is conformable to the severity of the symptoms. 



150 



CLINIQUE MÉDICALE. 



The patient presented ail the phenomena of abundant cérébral hemorrhage. The 
résolution of the four extremities explained by the pressure of the tumefied left 
hémisphère on the other. Could any one have inferred from the state of the 
patient on his admission the real nature of his disease ? We think not. But 
valuable assistance might have been furnished by the previous history. This 
person, be it recollected, had for a long time back, weakness of the extremities, 
and pain in the left side of the head. Such phenomena were connected much 
more with the idea of softening than of hemorrhage. It is probable that this 
softening, slowly formed, remained confined to a small extent of the left hémisphère 
up to the day the patient fell deprived of consciousness. Here again we have 
softening without hyperemia, for we must not refer to a state of sanguineous con» 
gestion the vascular network which appeared in the middle of the nervous mass. 
This network was the natural state. It is truly remarkable to see, whilst the 
nervous substance ail around is reduced to an almost liquid state, the vessels 
traversing it, and which must participate in its life. préserve their normal con- 
sistence — an admirable example of the independence of the vital action of différent 
tissues, though confounded in one and the same organ. Thus may be explained 
why a softening, however considérable, does not necessarily bring on a 
hemorrhage. 

Case 20. — Pain ofhead of the right side, ivith numbness of the left extremities for 
some days, then sudden loss of consciousness — Hemiplegia on left side — Softening 
ofthe middle part of the right hémisphère. 

This was the case of a woman, sixty-six years of âge, who complained of an 
acute pain in the right temple ; her left extremities seemed benumbed and heavy. 
After about a week her pain of head increased ; her right leg bent under her 
and she was put to bed ; a little after she was seen to put her hand to her head, 
and a little after she was deprived of consciousness. Some hours after she was 
brought to hospital : her state then was — Profound coma ; total insensibility to 
external impressions ; extremities of left side when raised fell again as inert 
masses ; respiration stertorous ; puise hard, seventy-two ; she died in the night. 

Post mortem. On the level of, and outside, the optic thalamus of the right 
side, there was considérable softening to an extent capable of admitting an 
orange ; this softening reached the posterior third of the corpus striatum, and a 
part of the optic thalamus. 

Remaries. — There was great resemblance between this case and the preceding : 
in the former the headach, which announced the cérébral disease, lasted for two 
years, whilst in the second it did not extend beyond a few days. In the latter 
case also, there was no hemiplegia, which is accounted for by the smaller extent 
of the softening, which did not, as in the fîrst case, exert any influence on the 
sound hémisphère. 

Case 21. — This was the case of a porter, who had been exposed for some time 
to the vapour of charcoal, after which ne suffered for three or four days dizziness 
and pain of head ; the dizziness went off, but the pain became concentrated 
towards the région of the left pariétal bone ; about a month after he fell down 
suddenly, deprived of consciousness and motion. The case bore a great re- 
semblance to the preceding two. 

Case 22. — Debility of the right extremities of long standing — Sudden loss of con- 
sciousness — Hemiplegia on the right side, and contraction on the same side — 
Convidsive movements and cataleptic phenomena of the left side — Softening in 
each optic thalamus. 

A man, seveuty-seven years old, full habit, complained for a long time of the 
right limbs being weaker than the left ; one morning he suddenly lost ail con- 



DISEASES OF THE ENOEPHALON. 



151 



sciousness, and was conveyed to the hospital, where he présentée! the following 
syinptoms ; — Incomplète hemiplegia of the right side ; left arm agitated with 
involuntary movements ; face flushed, expressive of stupor ; eyes closed ; left 
pupil slightly dilated, and the right contracted ; sensé of hearing impaired ; 
tongue protruded with difficulty, déviâtes a little to the left ; puise fréquent and 
small ; respiration embarrassed ; he was bled twice the first day of his admission, 
and had sinapisms to his legs ; after two days he seems better ; respiration easier; 
tongue more easily protruded, and déviâtes less ; he wishes to speak, but we hear 
only inarticulate sounds ; puise accelerated, small, a little more developed in the 
right ; the arm of this side performs some weak movements ; fore-arm flexed ; 
fing-ers also slightly so ; the left arm having been raised by mere chance, then left 
to itself, it was observed that it retained the various positions which had been given 
to it for a very considérable time ; the lower extremity of the left side did not 
exhibit this cataleptiform state. In two days after he seems still better ; stupor 
less ; opens his eyes and speaks ; answers questions accurately ; catalepsy of the 
left arm diminished. On the next day return of the stupor ; puise small ; right 
arm performs some movements and présents no signs of flexion ; left arm now 
contracts with force w T hen we wish to move it ; ail the symptoms becoming worse ; 
he died in a few days. 

Post rnortem. Strong adhésions between the dura mater anderanium ; mem- 
branes covering the anterior and middle part of the cérébral hémisphères thickened 
and a little opaque. In each of the hémisphères the following altérations were 
discovered : — 1 st. In the left hémisphère, the posterior and middle part of the 
optic thalamus presented a softening the size of a hazel-nut — here the cérébral pulp 
was converted into a yellowish bouillie. 2nd. In the right hémisphère, the optic 
thalamus présents a softening of small extent towards its internai posterior part ; 
in the centre of the softening, a small quantity of blood infiltrâtes the nervous 
pulp. 

Remarks. — Here at first view it is difHcult enough to connect the symptoms 
during life with the lésions found after death. It is probable that the graduai 
debility of the right side, which preceded the loss of consciousness, depended on 
the process of softening, which had already commenced in the left optic thalamus. 
This weakness was converted into paralysis, the same day on which the coma 
supervened ; and soon after this paralysis became complicated with flexions of the 
limbs. This succession of phenomena indicates a progress in the softening of the 
left optic thalamus ; and if, subsequently, the contraction disappeared, if the 
paralysis itself diminished, so that the patient became able to perform some move- 
ments with the right arm, we must thence conclude that the process of softening 
was arrested in the left optic thalamus, or that the inflammation accompanying it 
had become less intense. So far every thing is very well explained, but such is 
not the case with other phenomena, of which we have now to speak. What was 
the cause of the convulsive movements of the left arm r and of the cataleptiform state 
it subsequently presented ? Was it the softening, with sanguineous infiltration 
found in the right optic thalamus ? We do not think so ; for then the arm would 
not have recovered its movements. We think that the last mentioned phenomena 
depended on the partial meningitis, which was proved to have existed. It seems 
probable that the softening of the right optic thalamus took place only at a late 
period : to it we would refer the return of the coma, and the rigidity of the left arm 
the day before death. 

Case 23. — Sudden loss of consciousness and motion — Momentary return of intelli- 
gence— Delinum at intervais — Pain of head — Softening of one of the corpora 
striât a. 

A woman, forty-seven years old, was suddenîy seizeel with violent pain of head 
and dizziness : she could not sustain herself on lier legs, and staggered as if drunlu 



152 



CLINIQUE MÉDICALE. 



After some hours she lost ali consciousness ; she recovered a little in half an hour, 
but was paralysed on the right side ; she was brought to the La Charité ; we saw 
her about fifteen hours after the first attack ; intelligence weak ; still she could 
understand and answer our questions ; she gazed at us with an astonished air ; 
when asked if she surfered pain any where, she pointed to the head ; articulation 
difficult ; mouth dragged to left ; both extremities of the right side wholly 
deprived of motion ; sensibility of the skin covering them impaired. For the 
twenty days following, she continued nearly in the same state; only, occasionally, 
her intelligence became disturbed ; memory gone ; constantly complained of pain 
at the left side of the head ; she became emaciated ; appetite gone ; a large 
eschar on the sacrum ; tongue dry ; fœces discharged involuntarily ; she died in 
an adynamic state about forty-eight days after her admission ; delirium constant 
for the last eight days of her life ; she had been bled twice after entering the 
hospital, blistered at the nape of the neck, and some purgative mixture given her, 
Post mortem. Pia mater covering the convexity of the hémisphères infiltrated 
with a considérable quantity of turbid sérum ; the arachnoid was raised from it j 
a similar liquid filled the left ventricle ; left corpus striatum occupied by a soften- 
ing about an inch and half in length, and one inch in breadth. In the centre of 
this softening, which was of a yellowish colour, were seen three small red points. 
Ail the corpus striatum was in gênerai softer than on the opposite side, and the 
cérébral substance around it, for the extent of some lines, had also less than its 
natural consistence. 

Remarks. — The time which elapsed, in the case of this individual, between the 
first cérébral phenomena and the loss of consciousness, was shorter than in the 
others. Thèse phenomena were such as characterise cérébral congestion. The 
paralysis was not ascertained till after the loss of consciousness. The latter was 
of less duration than in the preceding cases. When the patient came to herself, 
her intelligence was still somewhat impaired, and embarrassment of speech was 
one of the prevailing phenomena. We call attention to this delirium, which 
manifested itself at a subséquent period, at first by intervais, and then in a 
continued manner. Was this connected with the state of the méninges ? Shall 
we find it accounted for in the turbid liquid which infiltrated the pia mater, and 
which filled the ventricle situated on the side of the softening ? At no period of 
the disease did we find contraction in the paralysed limbs. 

Case 25. * — Somnolence at first ; at a later period, momentary loss of consciousness, 
followed by hemiplegia — Death by heart affection — Softening of the optic 
thalamus and corpus striatum of the right side — Tubercular affection of the 
testicles — Aneurism of the heart. 
A man, forty-three years of âge, felt, for several years back, an habituai op- 
pression, which increased on every muscular effort. For the last year, the dyspnœa 
increased very much ; and for the last few months he perceived his left testicle to 
become very large. When he entered the La Charité, we were at first struck 
with the pale yellow tint of his face. He lay on his back in bed ; scarcely felt 
any dyspnœa when he abstained from motion ; sleep tranquil enough ; fréquent 
attacks of dizziness. The hand, applied to the prœcordial région, distinguished 
the beatings of the heart but very obscurely. When heard with the stethcscope, 
they were very irregular and tumultuous ; they were heard but very slightly along 
the sternum, and on the right anterior side of the thorax. Puise very small, 
irregular, occasionally imperceptible. We shall see how far thèse signs were from 
indicating the state of the heart. The patient presented no change in his state 
during the first month of his stay in the. hospital. At the end of this time he was 
observed to have a great tendency to stupor. Soon after he remained in a con- 

* We omit the 24th, as containing nothing very différent from the preceding. 



DISEASES OF THE ENCEPIIALON. 



153 



tinued state of somnolence. However, he was easily aroused, and then his 
intelligence was clear ; his movements were quite free. We asked him frequently 
whether he had pain of head, and he always answered in the négative. Respira- 
tion not more constrained than usual. This state of somnolence continued for 
three or four days, when one morning we were struck with the change in his 
puise ; it was small till then, but now became full and very hard ; skin unusually 
hot. During the night he suddenly lost consciousness ; he recovered it in about 
a quarter of an hour. On the next morning the left extremities, hitherto so free 
in their fonctions, were now deprived of motion ; the sensibility of the skin of 
thèse parts impaired ; right commissure of the lips drawn up, and at each expira- 
tion the left cheek is distended with air. In two days more the respiration 
became suddenly more difficult, and in about forty-eight hours he died, after 
having passed through ail the degrees of asphyxia. 

Post mortem. Cranium. — On the right side the corpus striatum and optic 
thalamus no longer existed. In their stead was found a soft white substance 
slightly rose-coloured in several points, yellowish in others. This morbid change 
reached, to the extent of from one to two inches, the nervous substance which 
bounds externally the corpus striatum from the optic thalamus. 

Thorax. — Lungs infiltrated with a prodigious quantity of frothy sérum. Heart 
of an enormous size, owing both to dilatation of its cavities and hypertrophy of its 
parietes. Not far from its apex, for a space equal to the size of a five franc pièce, 
the parietes of the left ventricle became suddenly very thin, scarcely equalling the 
auricles in thickness. In this part there existed interiorly a sort of pouch like 
the aneurismal sac of arteries ; parietes of right ventricle equally hypertrophied ; 
an enormous clot, of great density, filled its cavity, and extended into the auricle ; 
it adhered intimately to the arneae columnae of the ventricles. Was it formed 
during life ? Had it any sharein the production of the asphyxia? Aorta very large. 

Abdomen. — Liver gorged with blood ; intestinal mucous membrane generally 
injected ; a limpid colourless sérum efFused into the tunica vaginalis of the right 
side ; in the testicle of this side were found five or six small cavities filled with a 
substance like softened tubercular matter. 

Remarks. — Before the autopsy, what physician would not have admitted, in this 
case, the existence of cérébral hemorrhage ? Ail the symptoms appear to indicate 
it. The individual was affected with organic disease of the heart, and was for a 
long time subject to dizziness. There was a commencement of cérébral con- 
gestion ; then stupor cornes on, indicating a more serious degree of this congestion ; 
it lasted about five days, and terminated in sudden loss of consciousness, which is 
but momentary, and left a hemiplegia behind it. Might not one suppose that the 
simple congestion was succeeded by an effusion of blood ? This opinion seemed 
to dérive new support from the absence of ail headach, as of ail contractions of 
the limbs. It was also strengthened by the considération of the remarkable change 
the puise underwent some hours before the attack ; yet it was simple softening 
that existed. 

The loss of consciousness was momentary, as in several of the preceding cases ; 
but whilst in the latter, différent disturbances of the intelligence followed more or 
less immediately the return of the patients to consciousness, here, on the contrary, 
the intellectual faculties remained to the last perfectly ifitact. The affection of 
the brain no longer manifested its existence, except by the continuance of the 
hemiplegia : somnolence even, which preceded the loss of consciousness, no longer 
showed itself. Was it the influence of the cérébral disease which concurred in the 
production of the pulmonary œdema, of which the patient died ? We should be 
inclined to think so. 

We may here say one word of the remarkable lésion of which the heart was the 
seat, of that partial softening of the parietes of the left ventricle, which contrasted 



154 



CLINIQUE MEDICALE. 



so strikingly with the increase of thickness, which thèse parietes exhibited in the 
remainder of their extent. 

With respect to the symptoms of the affection of the heart, they certainly are 
worth remarking, if we compare them with the nature of the lésions discovered in 
this organ after death, The hand and ear applied over the région of the heart 
discovered no impulse there, notwithstanding the very great impulse which existed. 
The extent of the pulsations was not considérable, though the right and left cavi- 
ties were very much dilated. There was no obstacle, either at the origin of the 
aorta, or at the left auriculo-ventricular orifice, no contraction there ; nothing, in 
a word, which could explain the irregularity of the pulsations of the heart and 
arteries ; nothing either, which could account for the extrême smallness of the 
puise. This smallness depended certainly less on a material lésion appréciable by 
the scalpel, than on the manner of the heart's contractions, since it ceased alto- 
gether the day the patient was struck with apoplexy. The great fulness of the 
puise then, which contrasted so remarkably with its thready state the preceding 
days, was in some way the precursor of this attack. 

This case closes the séries of those in which the sudden loss of consciousness 
was one of the prédominant phenomena of cérébral softening. In ail the cases 
which we have cited, loss of consciousness was not the first symptom which an- 
nounced the affection of the brain. It was preceded by différent symptoms, such 
as pain of head, dizziness, weakness of the liinbs, paralysis, disturbance of the intel- 
ligence, stupor. Thèse phenomena preceded the loss of consciousness sometimes 
by some moments only, sometimes by several months. The loss of consciousness 
itself lasted but for some minutes, or was prolonged for several days. After it the 
paralysis which had preceded it was increased ; or if this paralysis had not existed 
previously, it was seen to supervene. In several of our cases, the loss of con- 
sciousness continued till death ; in others it ceased a longer or shorter time before 
the last moment ; and then sometimes the intelligence re-appeared in ail its per- 
fection, either for a continuance or temporarily ; sometimes the patient recovered 
his sensés only to fall into a delirium, which a little after terminated in a state of 
coma. 



ARTICLE II. 

SOFTENING OF THE BRAIN, WITH WEAKNESS OR PERVERSION OF THE INTELLIGENCE. 

Case 26. — Apoplectic attack four years before death — Complète recovery — Hemi- 
plegia supervening suddenly after some days of violent headach — Delirium. 

This was the case of a man seventy years of âge ; the precursory symptom in 
this case was an acute pain in the left side of the head, and painful numbness in 
the right hand, and staggering in his gait. After a fortnight, he was found one 
morning in a léthargie sleep ; on awaking, he was delirious, unable to articulate, 
and had hemiplegia of the right side. The latter diminished gradually, but the 
delirium continued till he died, which was thirteen days after the léthargie stupor 
was observed. 

The morbid appearances discovered after death were very inconsiderable, con- 
sidering the symptoms ; on the level of and external to the corpus striatum of the 
left side, there appeared a reddish spot the breadth of a franc. Here the tissue of 
the brain was quite soft, and looked as if some red colouring rnatter were mixed 
up with it. The left ventricle of the heart was hypertrophied. 



DISEASES OP THE ENCEPHALON. 



155 



Case* 28. — Delirium — Contraction of the lîmbs of the right side — Coma — Red 
softening of one of the hémisphères — Acute hydrocephalus — Bryness of the 
arachnoid. 

A man, nineteen years old, fell from a height of five or six feet, about fifteen 
days before his admission to the Maison de Santé. No bad symptom resulted at 
the moment ; but a few days after, he felt uneasiness, gênerai lassitude, and occa- 
sional shivering. After eight days passed on, he felt pain of head, and soon 
became delirious. He was bled, and had leeches to epigastrium ; delirium and 
fever still continued. Four days after the latter symptoms appeared, he was 
admitted to the Maison de Santé ; he then presented the following state :— Rapid 
alternations of coma and agitation ; face injected ; flexion of the right upper 
extremity ; the hand also flexed on the fore-arm of this limb, and the fore-arm on 
the arm ; puise ninety-six ; respiration stertorous ; tongue moist ; abdomen soft 
(twenty leeches on each side of the neck, a blister to the nape of the neck, 
sinapisms to the lower extremities, some purging mixture). 

Next day, continuai coma ; vision gone ; pupils moderately dilated ; froth at 
the mouth ; face injected ; strong flexion of the upper extremity ; right leg equally 
flexed on the thigh ; occasionally some convulsive movements in the flexed upper 
extremity ; cutaneous sensibility of both sides of the body destroyed ; respiration 
very stertorous ; puise 140 (ice to the head, sinapisms to the lower extremities, 
twelve grains of calomel). 

During the day, state of coma increases ; puise so fréquent and small, that it 
cannot be counted ; respiration more and more embarrassed, and the patient died 
in the night. 

Post mortem. Cranium. — Remarkable dryness of the free surface of the arach- 
noid. Anterior to the left corpus striatum was a softening capable of containing a 
hazel-nut ; this softening presented a well-marked tint. The ventricles were dis- 
tended with an enormous quantity of sérum, clear as rock water. The fornix and 
septum were reduced to a white difîiuent pulp. 

Thorax. — A great number of crude tubercles in the lungs : a quarter of a glass 
of limpid sérum in the pericardium. 

Abdomen.— Tubercles in spleen, which is dense and small in size ; slight injec- 
tion of the villous coat of the stomach ; small intestine pale ; red patcb.es in the 
caecum and ascending colon. 

Remarks.— Without seeking to establish how far there was a connection between 
the fall, which had happened to this person, and the disease of which he died, we 
shall merely observe that the first morbid phenomena occurred immediately after 
the fall. Thèse phenomena did not at first seem to be the resuit of a cérébral 
affection ; it was, in fact, a mere fébrile disturbance, without a«ny well-marked 
local symptom. At first, this young man experienced fatigue, and a degree of 
uneasiness, which constitute the precursor of the most différent diseases ; but very 
soon symptoms appeared, which more directly developed the affection of the 
encephalon ; however, the headach and delirium which complicated the fever, did 
not yet prove sufficiently that the disease had its principal seat in the nervous 
centres ; for how often do not similar phenomena présent themselves as the 
purely sympathetic resuit of the affection of another organ, and particularly of the 
intestine ? Such was also the opinion of the physician who first attended this 
person, since, after bleeding him from the arm, he applied leeches to-the epigas- 
trium. Again, could thèse alternations of profound coma, and convulsive agitation 
which the patient presented on his admission, have afforded us a certainty, that 
the brain was the organ particularly suffering ? Certainly not ; for, in many cases, 
thèse phenomena are referrible to a gastro-intestinal inflammation. However, the 

* Case twenty-seventh oniittcd., as containing nothing of particnlar importance. 



156 



CLINIQUE MÉDICALE. 



natural appearance of the tongue should be taken into serious considération, in 
order to establish the diagnosis : this might afford good ground for our presuming 
that we had not to do with a gastro-enterite, a dothinenterite, a typhoid lésion , 
and if the seat of the evil were not in the primae vias, we should conclude that it 
was in the brain. The flexion of the limbs of one side gave much greater weight 
to thîs opinion ; for this phenomenon is scarcely ever produced in conséquence of 
a merely sympathetic suffering of the brain. In the brain then the principal seat of 
the disease was ; but what was its nature ? Was there simple meningitis ? To this 
inflammation of the cérébral membranes might be referred the delirium and coma, 
convulsive agitation, and the modifications of the gênerai sensibilîty, the loss of 
vision, &c. But this well-marked flexion of the limbs, limited to only one side of 
the body, seemed to announce a lésion of the nervous substance itself ; if this 
lésion did exist (and for our part we think it very likely \ it could scarcely be any thing 
else than softening of an inflammatory nature. To sum up, there must be, in this 
case, meningo-encephalite. The autopsy warranted this mode of viewing the 
matter ; the red softening of a small portion of the cérébral substance had a very 
différent appearance from those white softenings, of which we found numerous 
instances in the preceding cases. The particular dryness, of which the arachnoid 
was the seat, was certainly not a normal state of this membrane, and we know that 
in most inflammations there is a period at which the sécrétions are suppressed. 
The great quantity of limpid sérum which filled the ventricles, must also have 
performed a part in the production of the symptoms. Again, the dryness of a 
serous membrane could not be an unanswerabie proof that it was inflamed. In 
order that it should cease to exhale its usual fluid, would it not be sufficient, that 
a great quantity of sérum should be suddenly separated from the blood, in other 
points of the System ? Is not that what happens in choiera, where, on opening 
the bodies, several great serous membranes are also found extremely dry ? We 
would conceive, also, that in conséquence of this unusual dryness, the organs 
enveloped by thèse serous membranes might be embarrassed in their functions, 
whence might resuit various symptoms falsely attributed to an inflammatory state. 
Nor is it impossible that certain states of the innervation might have some influ- 
ence in the dryness of the serous membranes. Does not a mental émotion 
suddenly deprive the buccal mucous membrane of its usual moisture ? 

Case 31. — Progressive disturbance of tJw intelligence terminating in complète 
delirium — Hemiplegia — Flexion of the paralysed limbs — Softening of one hémi- 
sphère. 

An Irishman, thirty-two years of âge, good constitution, having recently under- 
gone treatment for syphilis, when it was observed that his intellectual faculties were 
weakened, and his memory in particular impaired. By degrees his intellect 
became so dull, that he could express himself only with considérable difficulty. 
He was bled without any amendment. His friends then entreated me to admit 
him into my wards ; I saw him for the first time the 12th of May ; he presented 
the following state :— The patient lay on his back, and answered the questions 
put to him with great difficulty ; he complained of an acute pain in the head 
without being able to tell its précise seat ; puise eighty-four, and respiration 
sixteen every minute. Tongue white and moist. (Bled to sixteen ounces.) 

The blood drawn from the vein collected into a small clot, surrounded with 
much sérum, without being buffed. 

Ail the night he raved ; strait-waistcoat put on him. On the 13th, the 
agitation of the night succeeded by a state of somnolence ; from time to time he 
opened his eyes, and looked with a stupid air at ail around him ; answers slow 
and diffi.cult ; he said his headach was diminished ; the fingers of the hands, both 
rîght and left, were agitated by slight involuntary movements, and there was no 



DISEASES OF THE ENCEPHALON. 



157 



other appréciable disturbance in the locomotive faculties than this spasm of the 
fingers just mentioned ; respiration stertorous, as in apoplectic patients ; we 
counted twenty movements of inspiration each minute ; puise sixty-eight instead 
of eighty-four. (Twelve grains of calomel.) 

Vomited severely after taking the calomel ; no alvine déjection ; raved ail day. 

The 14th, in the morning, the delirium continued, but calm ; he pronounced 
some inarticulate words, but in a low voice ; he constantly held the right arm 
outside the bed, and gave it différent movements, which seemed directed towards 
laying hold of some object ; the right leg moved also, and he endeavoured to put 
it outside the bed ; such was not the case with the two extremities of the left 
side ; they remained immoveable along the trunk ; when the skin of thèse 
extremities was pinched, it was those of the right side that moved ; the expres- 
sion of the countenance then indicated that the sensibility continued ; we raised 
the left arm and it fell back but slowly, as if still sustained by a remains of mus- 
cular action ; he made no résistance to the movements of flexion and extension 
which we attempted to make it perform, but the muscles of this limb were 
agitated by slight convulsive twitches, which resembled a species of undulation 
beneath the skin ; puise now ninety-six, and small ; twenty-four respirations each 
minute. (Two blisters to the thighs.) 

On the 15th, the left extremities exhibited a rigidity which they had not the 
preceding day ; the fore-arm of this side was flexed on the arm, and it resisted 
the efforts made to extend it ; we thought bleeding might still be borne ; forty 
leeches were applied to the base of the cranium. 

On the 16th, the patient no longer exhibited any signs of intelligence; his 
ey.es, usually shut, were opened occasionally, and fixed with a stupid air towards 
some of the surrounding objects ; he directed his right arm towards them, which 
preserved ail its mobility ; the left upper extremity, deprived of motion, was still 
more flexed than on the preceding day, as was also the left lower extremity ; the 
sensibility appeared more impaired on the left side of the body than on the right ; 
puise 128 ; respiratory movements twenty-four ; pulsations of the heart extended 
over the entire chest ; the respiratory murmur everywhere strong and clear ; the 
subcutaneous veins very much swollen ; skin, still warm, covered with sweat ; 
constipation. 

In the course of the day were observed constant alternations of great agitation 
and profound coma ; he died at midnight. 

Post mortem. Cranium.— Membranes slightly injected. An immense softening 
in the right hémisphère, commencing at the circumvolutions of the posterior and 
middle lobes, and extending in depth to near the base of the brain. The optic 
thalamus and corpus striatum both reduced to a bouillie. This softening, in its 
eutire extent, présents a dull white colour in some points, and yellowish in others ; 
no appearance of any thing like effused blood or infîltrated pus. Very few vessels 
pass through it ; those observed in it are but the vessels of the normal state, the 
tissue of which is still preserved intact amidst the breaking down of the nervous 
substance. The left ventricle contains a tea-spoonful of reddish sérum. 

Thorax. — A glass-full of brownish sérum in the left pleura ; considérable 
infarction of the lungs ; some marks of pulmonary apoplexy in the inferior lobe 
of the right lung ; sanguineous suffusion under the pleura of the same side. Heart 
hypertrophied ; parietes of the left ventricle thirteen Unes in thickness ; those of 
the right ventricle four Unes, and the septum nine lines. 

Remaries. — The disturbance of the intellect was for a long time the prevailing 
symptom, more even than in any of the preceding cases ; it even showed itself 
without the complication of any other functional disturbance. This disturbance 
of the intellect was established but imperceptibly : it was gradually weakened. 
At the time we saw the patient, there was not yet any delirium ; but it soon 
manifested itself, not to cease again, coinciding- with alternations of violent 



158 



CLINIQUE MÉDICALE. 



agitation and profound coma. It was but consecutively to ail thèse disturbances 
of the intelligence, that motion itself began to be disturbed : the first phenomenon 
which apprised us of it was small convulsive twitches, extending to the two sides 
of the body. But characteristic symptoms soon appeared : thèse symptoms were 
paralysis of the left extremities, convulsive agitation of the muscles of thèse limbs, 
rigidity and ultimately flexion of them ; the latter continued till death. Then the 
most characteristic sign of softening did not appear till the close of the disease. 
This softening was one of the most considérable we have had an opportunity of 
seeing. Did it commence at the circumvolutions ? Was it in conséquence of this 
circumstance that the disturbance of the intelligence marked the commencement 
of the disease? 

In this case, as in the preceding, the membranes were not affected. Thèse two 
cases also resemble each other in this, that in both, the softened parts were not 
the seat of any sanguineous congestions. 

If we now direct our attention to the manner in which the différent functions of 
the life of relation were performed, during the course of this disease, the following 
remarks will présent themselves to us : the tongue was constantly in its normal 
state ; a circumstance which, from the very commencement, should lead us to refer 
the delirium to an affection of the encephalon, and not of the digestive organs ; 
the calomel, administered once in the dose of twelve grains, made the patient 
vomit, and did not remove the constipation. The puise, a little accelerated at 
the time of the patient's admission, became slow on one day ; then it became more 
and more fréquent till death. The very day of his death, there was remarkable 
energy in the pulsation of the heart. With respect to the respiration, it was less 
embarrassed, up to the last, than in other individuals, so that no symptom disclosed, 
during life, the existence of the serious lésions of which one of the lungs was 
the seat. 

We should have observed in the account of the post mortem, that there was 
considérable softening of the mucous membrane of the stomach, which extended 
to the subjacent tunics. Did this exist during life ? Was it not rather a pheno- 
menon which took place after death ? With respect to this matter, here is an 
extraordinary fact ; this person and three others were opened within a few days 
of each other, whilst the température was very high. In thèse four, who died of 
very différent diseases, we found the great cul de sac of the stomach softened to that 
degree, that the slightest drawing of its parietes produced a lacération of them. 
Some days after the température fell, and we found nothing similar in the other 
bodies we opened. 

Case 33. — Graduai weakening of intelligence and motion — Several parts of the two 
hémisphères softened. 
A man, sixty years old, was attacked, for the last year, with paralysis of the 
left side, which came on gradually, not preceded by any loss of consciousness. 
Simultaneously with the paralysis, the intelligence became weakened, and he 
gradually fell into a complète state of childishness ; at which time he entered the 
La Pitié. After a little his respiration became hurried ; fever developed itself; 
tongue dry ; in the inferior lobe of the right lung we detected intense inflamma- 
tion, * which was not removed by bleeding and révulsives ; and death soon 
followed. 

Post mortem. The right hémisphère of the brain the seat of two softenings ; 
one in one of the circumvolutions of its posterior lobe (at the base) ; the other 
immediately behind the ancyroid cavity, one inch and half in diameter ; thèse two 
softenings présent a reddish colour. In the left hémisphère there is a third soften- 
ing, seated in one of the circumvolutions of the middle lobe (upper surface): this 
softening presented a reddish tint, such as the two others ; ventricles distended 
by a great quantity of limpid sérum ; pia mater on the convexity of the hémisphères 



DÎSEASES OF THE ENCEPHALON. 



159 



infiltrated with sérum equally limpid ; this fluid raises the arachnoid, which is 
separated by it for several lines from the cérébral substance ; there is sérum also 
within the great cavity of the arachnoid. 

Thorax. — Red hepatisation of the inferior lobe of the right lung. 

Remarks. — Here again the intelligence and power of motion were weakened 
gradually, and from the commencement the disease presented the form and course 
of a chronic affection. The parts of the brain softened were injected in this case. 
Now, in other cases, we have seen this co-existence of hyperemia and softening 
connected with an acute form of the disease. The most remarkable circumstance 
is the number of softened points in the cérébral hémisphères, and also the existence 
of a small softening confined to a circumvolution of the left hémisphère, without 
there being, during life, any lésion of motion in the right extremities. 



SECTION II. 
re capitulation. 

In showing us softening of the brain under ail its forms, both anatomical and 
symptomatical, the preceding cases have also shown us, how far from being easy 
is the diagnosis of this affection in many cases. The study of thèse particular 
facts seems to us to be of extrême importance, by reason of the différent aspect 
under which each of them présents the disease to us. How could a gênerai 
description point out sufficiently ail thèse individualities ? Each fact has really a 
physiognomy of its own, and requires to be closeîy examined. In each of them it 
is not only the symptoms that are not the same, but again, it is that there are 
similar symptoms, which are connected together, or succeed each other in the 
most différent manner ; thence resuit, for one and the same anatomical lésion, 
several morbid forms which, in a nosological System, might be placed at a great 
distance from each other ; in some cases there is what is called an attack of 
apopîexy, with or without loss of consciousness : in others, it is a fever called 
ataxic ; at other times it is a graduai diminution, either of motion only, or 
simuîtaneously of intelligence and motion. See also how différent are the modi- 
fications which the latter may undergo ; complète or incomplète paralysis, 
convulsive movements, partial or gênerai, contraction, tétanie rigidity, limited to 
some muscles, or extending to ail the body, &c. How could you attain a percep- 
tion of ail thèse shades, if not by the study of the particular facts which represent 
them ? And add again, that some of thèse will show you cases, where not only 
the softening has no longer the symptoms which ordinaril.y occompany it, but in 
which there is not even a symptom which announces any lésion what e ver of the 
nervous centres ; so that sometimes the softening of the brain remains a lésion 
entirely latent. However, we should not confine ourselves to the mere considér- 
ation of thèse particular facts ; we should endeavour to possess ourselves, as far 
as possible, of the traits by which they differ, those in which they resemble each 
other, and thus dérive from our study of individualities gênerai conséquences. But 
however extensive thèse généralisations may be, let us not flatter ours-elves that 
they ever can take in the infinité variety of facts ; thence the necessity of recur- 
ring to them constantly, and of constantly interrogating observation, which alone 
can either enlarge or rectify our points of view. 

We have seen, in the preceding cases, that softening of the brain is far from 
presenting itself always on the dead body with the same anatomical characters. 
Thèse characters are, at times, so différent, that they seem to indicate a différence 



160 



CLINIQUE MEDICALE. 



in the nature of the lésion. There are, first, some cases, where the only change 
we can discover in the nervous substance, is the diminution of consistence ; it 
appears that either ail at once, or gradually, it returned, in a certain part of its 
extent, to the almost liquid state which, during fœtal life, constituted its normal 
state. It has, besides, its ordinary colour ; and we may still distinguish, by their 
différent tints, the grey substance and the white substance. At times, only, we 
see this softened part pervaded by a certain number of vessels ; but their présence 
is not a pathological state ; it is merely the vascular woof of the normal state, 
which remained intact in the midst of the softened pulp in which it was plunged. 
But this vascular woof, itself, is very far from being always distinguishable : there 
are cases where, far from being more coloured than usual, the part which has lost. 
its consistence is, on the contrary, remarkably pale ; it no longer contains a drop 
of blood ; its vessels have disappeared. This loss of substance may be appre- 
ciated in the grey substance particularly, which, in more than one case of soften- 
ing, can no longer be distinguished by its colour from the white substance adjacent 
to it. 

This loss of colour, noticed by M. Lallemand, was considered by him as the 
product of an infiltration of the cérébral substance by purulent matter. In several 
cases there is nothing to prove that it is so. When the softened parietes contain 
pus, they have a différent aspect, and it is easy to recognise it, as we shall pre- 
sently see. 

Here then, already, are two cases which, in référence to anatomy, should be 
distinguished from each other. In the first of thèse cases, the softening is the 
only morbid élément ; in the second, another is added to it, namely a state of 
anémia : it is, consequently, an élément the inverse of those which constitute 
inflammation. 

Then there cornes another case, fréquent, no doubt, but much less so than has 
been said : it is where a state of hyperemia complicates the softening. The 
portion of nervous substance, which has lost its consistence, then présents différent 
degrees of injection, from whence results a red colour more or less intense. 
Sometimes this red tint is gênerai ; sometimes it is scattered in points, more or 
less approximated, through the entire extent of the softening. In place of this 
simple injection, it may happen that we find within the softening real effusions of 
blood, variable in size and number. 

Instead of being penetrated by a superabundant quantity of blood, the softened 
part may become the seat of a morbid sécrétion, which is sometimes simply serous, 
and sometimes purulent. In the first case, we find the nervous pulp soaked, as it 
were, in a more or less turbid sérum, which holds suspended whitish or greyish 
flocculi, the only fragments of the cérébral substance which have still preserved 
any consistence. In the second case, pus of différent qualities infiltrâtes the 
softened parts, or else unités into cavities, and forms abscesses more or less con- 
sidérable. 

Do thèse différent appearances, which may be presented by softening of the 
brain, refer to lésions of a différent nature ? Are they but degrees, more or less 
advanced, of one and the same disease ? It is easy to prove that, in a consi- 
dérable number of cases, it is first injected, then softened, then secrètes pus. Tbis 
has been excellently well established by M, Lallemand. The softening is then 
one of the anatomical characters of inflammation of the brain, as it may be of ail 
other organs. But if, in other cases, we do not find within the softening any 
trace either of sanguineous injection, or purulent infiltration ; if we find there, in 
a word, no other altération but softening itself, will it not be an abuse of analogy 
to conclude that in thèse cases also, the cause which has deprived the brain of its 
consistence is inflammation ? A fortiori, will not one be induced to admit it in 
those other cases where the softened part has become, at the same time, the seat 



DISEASES OF THE ENCEPHALON. 



161 



of an anémia *? Observe, besicles, that among thèse cases of white softening, there 
are some which have formed very rapidly, after the manner of acute diseases, and 
in such cases it cannot be supposed that the softening has commenced by a san- 
guineous congestion, which would disappear, according as the affection would 
assume a chronic course. No doubt, those who refer the proximate cause of 
every disease to a defect of the normal stimulation, must necessarily make céré- 
bral softening enter into one or other of thèse states, and not finding in this altéra- 
tion the characters of an asthénie disease, they must regard it as an inflammation. 
In thinking so, they but follow their théories ; but for us, who think that in a 
crowd of morbid states, there is no more hypersthenia than asthenia, but mere 
perversion of the vital actions, we are no more obliged to consider the cérébral 
softening, or any other softening, as an inflammation, than tubercles as pneu- 
monia. It is a spécifie altération of nutrition which may supervene under the 
influence of morbid conditions widely differing from eaeh other. To endeavour 
to détermine thèse différent conditions is the task to be performed, a task difncult, 
no doubt, but of quite another importance from that on which médical men have 
occupied themselves in latter times, when they have wished to reduce every céré- 
bral softening to one of the forms, or one of the degrees of inflammation of the 
nervous centres. We are convinced that by proceeding thus men have entered 
on a course diametrically opposite to that which should lead to the truth. We, 
too, might collect groups of facts to demonstrate that softening is capable of being 
produced by différent causes of inflammation. Thus, we might find one group of 
facts from which it would resuit that commencing oblitération of the arteries which 
enter the brain, is one of the conditions which concur in the production of a cer- 
tain number of softenings. We might cite other facts which would show us a 
remarkable coïncidence between the impoverishment of the blood, or any other 
altération whatever of this liquid, and the softening of a great number of our 
tissues. Are there really so many causes of softening ? The future will décide, 
and will discover, no doubt, many other causes, which, in the présent state of our 
knowledge, we cannot even suspect. Ail that we affirm is, that it is necessary to 
seek elsewhere than in inflammation for the cause of ail softenings. It does not 
even seem to us that the présence of an unusual quantity of blood in the midst of 
a softened tissue, is a sufHcient proof that irritation is the cause of its softening. 
May it not be that this superabundant blood has flowed into thèse softened parts 
but consecutively ? See the case where after a limb has remained for a long time 
merely paralysed, it suddenly became rigid, convulsed, and contracted ; on 
opening the body, we often find, in such cases, one part of the brain softened, and 
at the same time reddened with blood ; reasoning may then lead us to admit, that 
the sanguineous congestion occurred but as a mere complication of softening, and 
that it is it which caused the phenomena of excitement to succeed the simple loss 
of motion. In order to explain a cause which simultaneously softened and 
reddened a tissue, shall we never see any thing beyond the mere fact of an irrita- 
tion which has acted on this tissue ? Is it then in the gums of a scorbutic 
subject that the cause résides, which has brought them at the same time to a state 
of hyperemia, and deprived them of their consistence ? 

Here, no doubt, are very many questions raised, which wait till facts rigorously 
observed shall corne to solve them. But it is enough, we think, that such ques- 
tions can be put, and that in the future progress of science their solution is pos- 
sible, to make one mistrust very much the opinion which refers every softening to 
an inflammation. Because the brain is softened after a blow on the cranium, is 
that a reason for saying that every time it shall have lost its consistence, it must 
have been previously irritated ? 

If science refuse to admit inflammation as the sole cause of softening of the 
brain, if it see in this softening several other causes, for the proof of which it waits 
for new researches. it is quite clear that the term encephalitis cannot be used as 

M 



clinique Médicale. 



synonymous with the word softening. Neither do we rhink it correct, to cail tuis 
altération capillary apoplexy, as M. Cruveilhier lias done. In a certain number 
of cases, to be sure, the softening is acconipanied, or rather complicated with san- 
guîneous infiltration, or effusions of blood more or less tnuitiplied ; but certainly 
it is not in the présence of tins blood that the essence of the disease consists. a.nd 
there are at least as many causes in which we do not find the least trace of it. 
The softening then raay be either a capillary apoplexy, or an encephalitis ; but it 
is not necessarily either the one or the other. 

Outside the softened parts, the brain and its membranes do not always présent 
the sanie conditions. The substance of the brain has ordinarily its usual consist- 
ence ; there are cases vrhere it is perceptibly injected ; at other times it is not so ; 
at other times it is even paler than usual. It may also be tumefied and increased 
in size : then the hémisphère where the softening exists présents a singular appear- 
ance ; its circumvolutions are, as it were, heaped one upon another, and there are 
cases where, passing the médian line, it acts upon and compresses the hémisphère 
of the opposite side. 

There are other cases where persons affected with softening of the brain, which 
has already lasted for a considérable rime, hâve died of hemorrhage which took 
place in another point of the encephalon ; an instance of this has been given. 
With respect to the investing membranes, they often hâve their physiological 
appearance ; in several of the cases we have cited, the pia mater was traversée! 
by mimerons vessels ; in others a limpid or slightly turbid sérum infiltrated it. 
The ventricles presented to us more than once considérable dilatation, the resuit 
of the o-reat quantity of limpid sérum which filled them. 

Thèse différent altérations of the nervous substance, or of its membranes, cer- 
tainly perform their part in the production of the symptoms which accompany 
softening of the brain ; they may précède it, be developed simultaneously with it, 
or only a longer or shorter time after it. The injection of the pia mater, its 
infiltration by a turbid or transparent liquid, may be gênerai ; but we have 
seen cases where thèse changes were partial ; they were limited to the parts of 
the membranes extended over the points of the brain which had lost their con- 
sisteriez 

There are cases where the most apparent lésion is that of the méninges : in 
some cases the softening affects only the superficial layer of the circumvolutions ; 
we must then raise very cautiously the pia mater in order to ascertain this soften- 
ing : in such cases, portions of the cérébral substance are detached with the 
membrane. In certain cases of chronic meningitis, the softening does not exist 
immediately beneath the pia mater ; it occupies the deep plane of the circum- 
volutions, whilst their superficial plane remains in its normal state, or is indurated. 

In what state are the différent organs found in individuals who have died with 
softening of the cérébral hémisphères ? This question is important, whether we wish 
to establish what are the altérations which this softening may induce in other 
parts, or whether we wish to seek what are the conditions of the System which 
most frequently précède softening of the brain. 

Only one organ seems to us to receive a direct influence frorn the cérébral 
lésion ; that organ is the lungs. We have been struck, in our post mortem 
examinations, with the great serous infarctions of which the lungs were frequently 
the seat. It is of the affection of this organ. also, that several individuals die 
who are affected with cérébral softening. It is to the state of asphyxia in which 
they die that we must refer the bright redness presented in them by the gastro- 
intestinal mucous membrane. If we re-peruse, on this subject, the cases already 
quoted, we shall find accordingly, that the cases in which the lung has been found. 
after death, most infarcted with sérum, are those where we have met most intense 
hyperemia in the mucous membrane of the intestinal tube ; but tins hyperemia 
was altogether mechanieal. 



DISEASE3 OF THE ENCEPHALON. 



163 



With respect to the organic lésions which existed before the softening, we bave 
met a certain number. We shall présent a view of thera. 

In twenty-one cases the heart presented no appréciable lésion ; in nine cases 
it was aneurismatic ; in one case the aortic valves were ossified ; in tvvo other 
cases the heart itself presented no altération, but the two layers of the pericardium 
adhered closely to each other by old cellular adhésions. ïn one of the subjects, 
whose heart was hypertrophied or dilated, there was at the same time aneurism of 
the aorta. 

The blood did not, in any case, présent particular qualifies. The lungs were 
sound, or merely œdematous, in eighteen cases ; they were raeîanosed at their 
summit in one case ; they contained tubercles in seven cases, and cretaceous 
concrétions in two cases ; twice they presented traces of récent inflammation (red 
or grey hepatisation) ; and other three times we ascertained the existence of 
pulmonary apoplexy. In the two subjects where this apoplexy was met, the 
heart was hypertrophied and the lungs infarcted ; in one of them we observed, in 
the sub-pleural cellular tissue, well-marked sanguineous suffusion. 

The digestive organs were found exempt from ail appréciable lésion in fourteen 
cases ; Ave times they were injected in différent points of their extent ; in eight 
individuals the mucous membranes of the stomach had that brown or slate colour 
hue which is one of the anatomical characters of chronic gastritis ; in two cases 
the stomach was the seat of a cancerous affection ; in the subject of the second 
case, the cancer existed also in the liver and kidneys ; the stomach presented 
greater or less softening, either of its mucous membrane alone, or of ail its tunics 
in three cases. Finally, we found ulcérations in the intestines in three individuals 
whose lungs contained tubercles. 

The liver presented no perceptible altération, except in four cases ; it was can- 
cerous in two subjects (cases 2, 8) ; there was cyrrhosis of it in a third, who had, 
at the same time, ascites (case 9) ; and, in a fourth, it underwent the fatty dégé- 
nérescence (case 10). 

In one case, in fine, we found numerous tubercles in the lungs, liver, spleen, 
kidneys, intestines, and, at the same time, there were some in the pia mater, 
pleura, and in the peritonœum (case 25). 

In the subject of case 28th, there were at one and the same time tubercles in 
the lungs and spleen, without there being any in the intestines. 

It follows, from the account which we have just now presented, that among the 
thirty-three individuals, whose history we have given, there were but very few, ail 
whose organs were sound at the time their brain was affected with softening. 

The cérébral hémisphères do not soften with equal frequency in the différent 
points of their extent. On analysing with respect to the seat of the softening, on 
the one hand our own thirty-three cases, and on the other hand 117 cases pub- 
lished by différent authors, and in which the seat of the lésion was precisely 
indicated, we found as follows : — 

CASES. 

Softening of the entire of the hémisphères, ... ... ... 4 

of only one hémisphère in almost its entire extent, ... 13 

of the circumvolutions alone, ... 14 

— of the circumvolutions and other more dceply-seated parts, 9 

of the anterior lobes, ... ... ... ... ... 27 

of the middle lobes, ... „ 37 

■ — of the posterior lobes, ... ... ... ... ... 16 

of the corpora striata, ... ... .,. ... 28 

— of the optic thalami, ... 15 

of the parietes of the ventricles, ... ... ... 2 

of the cérébral peduncles, ,.. ... ... ... I 

■ dispersed through différent, points, .... ... 5 

M 2 



164 



CLINIQUE MEDICALE. 



It has been said, that, in thèse différent parts, the grey substance vvas more 
frequently softened than the white. We do not think this opinion sufïicientlv 
proved. In the softenings which occupy the nervous mass situated above the 
ventrieles, there is certainly much more of the white substance engorged than of 
the grey, and the preceding table shows us that thèse softenings are very fréquent. 
In the cases of softening of the corpora striata, it is not their external grey cortex 
that is most frequently affected ; far from it, it is most usually intact, and the 
softening exists in its interior, and then both the grey and white substance are 
found equally deprived of consistence ; the circumvolutions, where much grey 
substance exists, are far from being the parts most frequently softened. In several 
of the cases, the softening commences immediately beneath them, thus leaving the 
grey substance intact, and attacking the white exclusively. In conséquence of 
the greater quantity of vessels contained by the grey substance, the frequency of 
its softening might become a further argument to be adduced in favour of the 
opinion of those who admit, that every softening is preceded by an inflammatory 
congestion ; we may now judge of the weight of this argument. 

The two cérébral hémisphères are softened with nearly equal frequency ; we 
may satisfy ourselves of this, by looking to the following table, which results from 
the analysis of our thirt}*-three cases, and of 136 other cases borrowed from 
différent authors. In ail thèse cases, the softening was produced spontaneously, 
and we have not taken into the account those in which the brain lost its con- 
sistence in conséquence of external violence, or a disease of the bones. 

In thèse 169 cases, the softening took place — 

TIMES. 

In the right hémisphère, ... ... 73 

In the left hémisphère, 63 

In the two hémisphères at once, ... ... ... 33 

Most frequently we find in a hémisphère only one point softened ; sometimes, 
however, we meet several of them separated by intervening spaces, in which the 
cérébral substance has its normal consistence. We have given some cases of this 
kind. 

With respect to the extent which the softening may occupy, it is very variable : 
it may attack the entire of the two hémisphères, occupy only the entire of one, 
be confined to one lobe, to a portion of this lobe, and, in fine, at the other 
extremity of the scale we find cases in which a hazel nut could scarcely be con- 
tained in the space occupied by the softening ; and yet serious symptoms have 
been produced by a lésion so circumscribed. Now, we may conceive the production 
of thèse symptoms in several ways ; w r e may attribute it to the mere fact of 
disorganisation of the softened parts, or to the irritation felt by the rest of the 
encephalon, an irritation which sometimes évinces itself in the dead body by 
différent lésions, and sometimes leaves, after death, no trace of its existence. The 
hémisphère opposite to that in which the softening is, may be affected also in a 
manner altogether sympathetic, and it is thus we may conceive gênerai disturbances 
of motion and sensation, connected with a softening which occupies but a very 
circumscribed point of one of the hémisphères. 

There is no period of life in which cases of cérébral softening have not been 
observed ; its existence has been ascertained in mere infants, and in persons 
eighty-nine years old. 

We cannot make use of the cases which have been published on softening of 
the brain, in order to deduce from them the médium of the âge of individuals most 
liable to it. For this, in fact, it would be necessary that the same task which was 
performed by M. Rostan at the Salpétrière, should be undertaken, for example, at 
the Hôpital des Enfans. 

Passing over then the very small number of cases published up to the présent 



DISEASES OF THE ENCEPHALON. 



165 



day, on softening of the brain in children, and comprising in our analysis only the 
cases of individuals of from fifteen years old and upwards, \ve found that out of 
153 cases of softening, the âges were distributed as folio ws : — 





CASES. 




CASES. 


15 to 20 years old, 


10 


55 to 60 years old, 


18 


20to25 


9 


60 to 65 


8 


25 to 30 


9 


65 to 70 


26 


30 to 35 


6 


70 to 75 


19 


35 to 40 


5 


75 to 80 


11 


40 to 45 


9 


81 ... 


2 


45 to 50 


10 


87 - 


1 


50 to 55 


9 


89 ... 


1 



Thus, from the âge of fifteen to forty we find, in this table, but thirty-nine 
individuals vvho have had softening of the cérébral hémisphères ; from forty to 
sixty-five, we find fifty-four ; and from the âge of sixty-five to eighty-seven years 
there are sixty. The âge which gives us the highest number is the period of life 
included between sixty-five and seventy-five years*. 

With respect to the period of life comprised between birth and the âge of 
fifteen years, cases are not wanting to show that, even during that time, the 
cérébral hémisphères may also be softened. Billard, in his Traité des Maladies 
des Enfans Nouveau-nés, has mentioned cases of fœtuses, which, on coming into 
the world, or a very little time after birth, presented a softening of the brain either 
partial or gênerai. Other cases of softening of this organ have been published, in 
subjects of the âge of one year, three years, four years, five years, nine years, 
twelve years, thirteen years, fourteen years. One of the most remarkable cases of 
this kind is that, for the knowledge of which we are indebted to Dr. Deslandes. 
In this case, of a child of three years old, ail the substance of the brain, cerebellum, 
and pons, were reduced to such a state of softening, that it could not be touched 
without being destroyed ; this substance presented no trace of injection ; there 
was not a drop of sérum in the ventricles ; the pia mater was red. 

It has been stated that, in an anatomical point of view, softening of the brain, 
in old men, difTered from softening of the brain at other periods of.life. From 
our researches on this subject, it results, that softening, not complicated with 
hyperemia, is more fréquent in old âge ; but it is also found at ail other âges, and 
it is far from being rare in infancy. At the time we were collecting some cases 
at the Hôpital des Enfans, we remember to have found many times several parts of 
the brain reduced to a soft consistence, without thèse parts being in the slightest 
degree injected. We have met in particular a complète softening of one of the 
optic thalami, without its colour being at ail afFected. 

Is the one sex more disposed than the other to softening of the brain ? This 
question might be easily solved, if an exact account were kept for some years of 
the number of cases of this disease, observed at the Bicêtre and the Salpêtriere. 
In the published cases, we found more females than maies ; but this may be owing 
to the circumstance of there not having being performed at the Bicêtre, a task 
similar to that performed at the Salpétrière by M. Rostan. Let us pass by then, 
the cases of the latter physician, they being ail connected with females, and let 
us see what information we may dérive from other cases collected indiscriminately 
in subjects of both sexes. 

In the cases we have cited, there are more maies than females, twenty of the 
former, thirteen of the latter. But it must be observed, that a considérable num- 

* The éléments with which we drew up this table are: — lst, Our own 33 cases; 2nd, 40 
cases of M. Rostan's ; 3rd, 36 from M. Lallemand's work ; 4th, 10 published by M. Bouillaud; 
5th, 45 which we found in différent periodical works. 



166 



CLINIQUE MEDICALE. 



ber of thèse cases were collected in an hospital (the La Chanté) where maie 
patients were in much greater number than females. The numerical resuit might 
then only lead us into error, if we do not take into account the circumstances 
under which it was eoraputed. In 116 cases, published by différent writers, in 
which the sex was noted, we found that there were forty-seven maies, and sixty- 
nine females. But here again it would be necessary to know, in what proportions 
the individuals of the two sexes were distributed in the hospitals, in which the 
cases were collected. 

Except the cases in which the softening of the brain succeeds to external 
violence on the cranium, the circumstances, under the influence of which it is 
producecl, can be but very seldom ascertained. In some it cornes on in the midst 
of perfect health ; in others it is formed during the progress of différent chronic 
diseases, without our being able to assert that the latter perform any part in 
its production. Without dwelling longer on this so obscure point of the history 
of ramollissement of the brain, let us now proceed to consider the différent 
syinptoms which during life indicate its existence with more or less certaintj". 

The intelligence, motion, sensation, undergo, in conséquence of softening of the 
brain, différent modifications, which we shall now détail. 

The state of the intelligence is far from being always the same. In the first 
place there are cases, and very many cases, in which it préserves ail its integrity. 
At other times the intellectual faculties are completely abolished from the com- 
mencement of the disease : this happens when the latter commences by a sudden 
îoss of consciousness, or by a state of coma ; after a time, which in gênerai is 
variable, the intellectual faculties are re-established, sometimes entirely, which is 
rare, sometimes only in part, and then the individual has his intelligence dull and 
impaired until death. 

In a third case, the intelligence never entirely disappears ; but either from the 
commencement, or subsequently, it undergoes a perceptible weakening, and this 
weakening continues to the last. The persons who are in this case, have, as it 
were, a stupid air ; some présent that air of stupor, which is one of the characters 
of typhoid fever to a certain extent ; their answers are slow and uncertain ; they 
have but little meraory, little connexion in their ideas ; they seem also to have 
but little wants : they appear sunk in a sort of idiotism, or state of infancy : several 
présent a state of almost continuai somnolence. In some this drowsiness is the 
prevailing phenomenon during the entire course of the disease. 

Lastly, we have adduced several cases, in which the intelligence was disturbed 
to such a degree as to give rise to delirium. This may manifest itself only at 
intervals, or exist continually. In some patients, the delirium appears from the 
commencement ; in others, it cornes on only at a more or less advanced period of 
the affection ; we occasionally see it alternate, either with intervais of reason or 
with a state of coma. 

In some subjects, the form of the delirium is such, that there is observed real 
mental aliénation. 

Thèse différent states of the intellectual faculties may show themselves one 
after the other in one and the same individual. 

With thèse différent modifications of the intelligence, soeech ma/ be preserved, 
or eîse be entirely lost. Among the cases which we nave cited, some regard 
individuals, who, though appearing to have ail their intelligence, were absolutely 
unable to articulate a single word. 

We have seen some cases, and authors also mention others, in which intelli- 
gence, lost or perverted during the entire course of the disease, suddenly resumed 
remarkable clearness some hours before death. 

Are thèse différent states of the intelligence connected with the nature, seat, or 
extent of the cérébral lésion ? or, in the présent state of our knowiedge, can they 
be explained only by a peeuliar disposition of the nervous centres, which, with a 



DISEASES OF THE ENCEPHALON. 



167 



lésion altogether identical are capable of undergoing functional modifications of 
the most dissimilar kind ? We shall see how far observation will inform us on 
tins subject. 

Let us first inquire what are the anatomical conditions in which the encephalon 
is found in the individuals whose history we have detailed, and let us ask our- 
selves whether any connexion can be established betvveen thèse différent con- 
ditions and their intellectual state. 

Sixteen subjects, that is, nearly half of our patients, presented no disturbance in 
the intelligence at any period of their illness. Among them, however, is one 
(case 11) who, the last day of his life, fell suddenly into a state of coma, in the 
midst of which he died. In thèse sixteen cases, we ascertained in the encephalon 
and its appendages the following state : — 

In six patients the méninges were pale, of normal consistence, and no liqukl 
inriltrated them. In six others, the arachnoid covering the convexity of the 
hémisphères was separated from them by a limpid sérum situated in the pia 
mater : the sérum was small in quantity, except in one case (case 3), where the 
ventricles were at the same time filled with a quantity of sérum sufficient to 
distend them. In another subject, some sérum infiltrated the pia mater of the 
upper surface of the brain, but it was turbid : this was in the individual in whom 
the coma supervened on the day he died. In tvvo cases only this membrane was 
injected, and in one case the arachnoid and pia mater were changed into a dense 
opaque tissue, as serous membranes are, or rather the celiular layers which line 
them, when chronic inflammation has attacked them (case 4). This morbid state 
of the méninges was confined to the portion of the cérébral substance affeeted 
with softening. 

In none of thèse sixteen cases did the brain présent any altération outsîde 
the softened parts, except in the subject of the eleventh case, who had coma on 
the last day, and in whom the hémisphère, not softened, presented in an accurately 
circumscribed point a very bright injection. 

In thèse sixteen cases, the softening itself was found thirteen times whitish oï 
greyish, as the cérébral pulp should be ; three times only it presented a com- 
plication of hyperemîa. 

From considering what has been already detailed, we find that our cases of 
softening, where there was disturbance of intellect, did not differ materially from 
the cases where the intelligence remained intact, either with respect to the state 
of the méninges, or the state of the brain itself, considered external to the soften- 
ing and within the softening. 

Thus the présence or absence of disturbance of intellect, in cases of cérébral 
softening, seems to dépend much less on the nature of the altérations discovered 
after death, than on the mode peculiar to each subject, according to which the 
irritation extends itself from the softened parts to the rest of the encephalon ; the 
traces of this irritation are not such as the scalpel has been as yet able to discover. 
Thus, then, the infinité variety of the symptomatic forms of a disease can no 
more be explained, in many cases at least, by the différent conditions in which the 
organ which is the seat of them is found, than we can account for the différent 
modes according to which, in each individual, one and the same function is per- 
formed by the anatomical différences in the part which is the instrument of them. 

Thus then we find, as well by our own observation, as that of others, that sof- 
tening of the brain, most différent in its seat, extent, and even in the state of the 
surrounding parts, may be equally accompanied with disturbances of the intel- 
ligence. 

With respect to the cases in which the intelligence is always preserved or 
promptiy recovered, we shall find them equally with and without lésion of the 
periphery of the brain. 

The disturbance of the intellectual facuhies can no longer bc regarded as more 



168 



CLINIQUE MÉDICALE. 



particularly connectée! with softening of the anterior or posterior lobes, as some 
have asserted. Numerous facts prove that the lésion of thèse différent lobes is 
equally followed by deîirium or any other disturbance of the intelligence. 

In the case where the disease commences by complète loss of consciousness. 
the softening occupies in gênerai a great extent, as a great number of facts prove. 
However, in some cases of this kind, softenings have been found by no means 
extensive, considering the severity of the symptoms. 

From numerous cases, we feel warranted in laying it down, that it is impossible 
to establish rigorously, from the existence or nature of the functional disturbance, 
the seat and extent of the softening. _ 

Of the différent disturbances of intelligence which may accompany softening of 
the brain, there is not one which, by its spécifie form, can sufBce to point out, dur- 
ing life, the nature of the altération affecting the encephalon. Simple injections, 
either of the méninges ov nervous substance itself, considérable accumulation, 
either around the brain or in its ventricles, hemorrhage which bas lacerated its 
substance, accidentai pro'ducts therein developed, may, in fact, equally produce, 
either delirium with ail its varieties, or mere weakness of intellect, or sudden loss 
of consciousness. 

In some of the subjects, whose cases we have recorded, one of the most promi- 
nent phenomena was loss of speech. The facts which we have recorded on this 
subject, tend to prove that the efforts made at différent periods, to assign to certain 
parts of the brain the faculty of articulating and arranging language, are, at îeast, 
prématuré. We already discussed this question when on the subject of cérébral 
hemorrhage. 

Softening of the cérébral hémisphères induces altérations in motion much more 
constantly than in intelligence. However, even this rule is not without its 
exceptions, and we have cited some cases in which we did not observe, in référence 
to motility, any appréciable modification. In the four cases of this kind which we 
have recorded, the softening occupied the most différent seats. One fime it was 
limited to some circumvolutions of the convexity ; another time it occupied, at the 
base of the anterior lobe of one of the hémisphères, a space large enough to con- 
tain a pullet's egg. Two other times it occupied several points of the two hémi- 
sphères (cases 1, 2, 3, 4). Several cases, however, are on record, in which 
softening of the brain existed without any disturbance of motion having been 
observed*. When this does happen, it is probable that the softening takes place 
very slowly. Such cases remind us of those in which the brain, subjected to a 
graduai compression by tumours developed around it, or in its substance, does not 
announce its suffering by any paralysis or other disturbance in locomotion. 

When motion is affected, (and this case may be regarded as nearly constant), it 
is very far from being always affected in the same way. It has been laid down 
much too generally, that softening of the brain produced, in the greater number of 
cases, a flexion (contracture) of the limbs. Observation has satisfied us that this 
flexion may be as often absent as it is présent ; but it is very true, that when it 
does occur, it becomes an excellent sign to distinguish a softening of the brain 
from every other affection of this organ. Let us not, however, regard such a sign 
as pathognomonic ; for it has been found in other cases where there was no 
softening. It has been often noticed, for instance, in the cases of congénital 
atrophy of the brain, published by MM. Bouchet and Casauvieilh {Archives 
Générales de Medicine, tom. ix). 

The modifications which motion undergoes, in cases of softening of the brain, 
are far then from being always of the same nature. Thèse modifications most 
usually consist either in simple paralysis, flexion of the limbs, or in convulsions. 

* See Répertoire <T Ânatoniie et de Physiologie Pathologique, par Brescliet, tom. i. p. 110, 
al?o Journal Hebdomadaire, tom. iv. p. 270. 



DISEASES OF THE ENCEPHALON. 



169 



There are otber cases then in which motion is modified in quite a différent way : 
we shall return to that subject presently. 

The paralysis présents différences with respect to its degree, its progress, and 
its seat. 

There are cases where it cornes on but gradually. The patients perceive that 
one of their extremities has less strength than the other ; one of their hands can 
hold objects less stron°:ly than the other ; they feel an awkwardness in using it ; 
one of their arms appears insensible to them, or their leg drags a little in walking. 
This commencement of paralysis may remain stationary for a long time ; then it 
is seen progressively to increase ; or else it becomes ail at once more considérable. 

In other cases the paralysis does not pass through thèse différent degrees ; it 
cornes on suddenly, and, from the ôrst moment of its appearance, it is as complète 
as possible ; it bears the greatest resemblance to the paralysis resulting from an 
effusion of blood into the brain. 

When the paralysis is established but gradually, it shows itself only on one side 
of the body, unless the softening itself exist in the two hémisphères. When it 
suddenly acquires its highest degree of intensity, the case is the same, at least in the 
greater number of cases. Sometimes, however, it takes place on the two sides, 
though the softening may not be double ; but that scarcely happens except when 
on the side where it has occurred, the softening may be very considérable. Then 
two things may happen : either the gênerai paralysis continues till death, which 
soon takes place ; or else, at the end of a certain number of hours, the moveraents 
of one side again become free, and there remains but hemiplegia. 

The flexion [contracture) présents, in its différent degrees, in its mode of appear- 
ance, in its progress, and its seat, the same différences as simple paralysis. As 
the latter, it may corne on slowly, and increase in a manner quite graduai. Thus 
we see some individuals in whom the flexion continues for a long time confined 
to one single phalanx, or to one finger ; then it extends progressively to the 
other fingers, to the entire hand, andfinally to the fore-arm ; the same progression 
takes place for the lower extremity. Once established on one of thèse points, it 
does not continue there always : there are some hours, and even some days, when 
it disappears to re-appear a^ain, In its absence, sometimes, the parts which were 
the seat of it recover the entire freedom of their morements ; sometimes they are 
weak, benumbed, on the road to paralysis, orfinally they continue really paralysed. 

The flexion (contracture) may also, as well as the paralysis, corne on suddenly, 
and attain at once its maximum of intensity. It is by a violent flexion of one 
limb, or of the two limbs of one side, that a certain number of cérébral softenings 
actually commence. Under this form, the flexion indicates the nature of the dis- 
ease with much more certainty than when it is established gradually. 

Once produced, the flexion may continue, becoming either more and more 
intense, or diminishing, or remaining in the same state. But it may also disappear ; 
there are cases, for instance, where it lasts only some hours ; there are some 
where it ceases at the end of an extremely short time, where it shows itself for 
scarcely a few minutes ; is then succeeded by simple paralysis. Once it has dis- 
appeared ; it sometimes no longer shows itself again, sometimes it returns at 
certain intervais. 

Besides paralysis and flexion, softening of the brain may again produce con- 
vulsive movements, which take place, as other lésions of motion, on the side of the 
body opposite to the softened hémisphère. There are some cases, where thèse 
convulsions mark the commencement of the disease ; they cease after a longer or 
shorter time, and are succeeded by paralysis or flexion ; at other times, they corne 
on at a later period, and replace momentarily the abolition of motion. 

Instead of being confined to one side of the body, the convulsions may be 
gênerai, either every time they show themselves, or only from time to time. lu 
the second case, it has happened more than once that there has not been fouud in 



170 



CLINIQUE MÉDICALE. 



the hémisphère opposite to that where the softening has taken place any lésion 
which could account for this momentary généralisation of the convulsive raove- 
ments. In the cases, on the contrary, where the convulsions remain always 
gênerai, we have been able almost always to discover lésions in the two hémi- 
sphères, or around them. 

We have now considered the great modifications which motion undergoes in 
cases of softening of the cérébral hémisphères. Wit'h respect to the parts of the 
body in which the power of motion is injured, they vary for cérébral softening as 
well as for cérébral hemorrhage, and we refer to our observations on this last 
affection for ail the questions regarding the détermination of the seat of the para- 
lysis, or of any other disturbance of motion. Only we shall here observe that, 
among the cases of softening which we have detailed, there are several which 
seem to us to form a very strong objection to the opinion of those who thought 
they discovered in the brain the particular parts which préside over the motion 
of the upper and lower extremities. Very probably, thèse particular parts do 
exist, since each limb may be separately convulsed, paralysed, &c, but it appears 
to us that thèse particular parts are yet to be found out, and we know nothing 
which can be so fatal to the sound doctrine of the localisation of the cérébral 
functions, as those prématuré localisations which some persons have been inclined 
to establish in latter times. 

, There are some rare cases in which the softening of the cérébral hémisphères 
gives rise to disturbances of motion, différent from those of which we have 
hitherto spoken. Thus, in some individuals, there have been observed symp- 
toms of tetanus, either partial or gênerai ; in others, epileptic symptoms have 
been observed. 

Lésions of sensation have also their importance when it is an object to establish 
the diagnosis of softening of the brain. Thèse lésions may be seated either in the 
head itself, or in other parts of the body. The head is often the seat of a pain, to 
which we must first direct our attention. 

This pain, which has been remarked by ail observers, shows itself in a considér- 
able number of cases ; but it is far from being constant, as may be seen by 
perusing the cases already cited. 

When it does exist, it shows itself most frequently at the commencement of the 
disease ; it may then précède ail the other symptoms, and continue" single for a 
certain time ; we have recorded cases, in which individuals were attacked with 
headach for fifteen days, twenty-five days, and even more, without presenting any 
other dérangement in their health. Ordinarily, this precursor, marked by head- 
ach alone, lasts a shorter time, from some hours to five or six days. 

There are other cases where, from its commencement, the pain of head is 
accompanied by divers phenomena ; but sometimes thèse phenomena are not yet 
of the number of those which may serve to indicate it. Thus, in some of our 
patients, we have seen the pain of head complicated, from the moment of its ap- 
pearance, or soon after, with dizziness, vertigo, tinnitus aurium, unusual redness 
of the eyes and face : thèse symptoms announced nothing yet but mere cérébral 
congestion. But on other occasions, at the same time that the pain of head cornes 
on, it is complicated either with a diminution in the activity of the intellectual 
faculties, or some lésion of motion. The latter may be so very inconsiderable, 
that the patients themselves do not call the attention of the physician to it, their 
thoughts being ahsorbed by the pain of head. 

Once corne on, the pain of head may continue with variable degrees of in- 
tensity ; but it often ceases, according as the lésion of motion becomes more 
marked. Many patients, who still retained ail their intelligence, have assured us, 
that, at a certain period of their complaint, they no longer felt the slightest trace 
of the pain of head, which at first had occasioned them so much anguish. We 
most not suppose, however, that the headach no longer exists in those persons 



DISEASES OF THE ENCEPHALON. 



171 



wlio cease to complain of it : it seems to continue, for instance, in several patients, 
who sunk in deïirium or corna more or less profound, continually apply the hand, 
that remains free, tovvards their head, and even tovvards a particular part of the 
head. At other times, when their intelligence is as yet only impaired and 
blunted, and they happen to be asked whether they feel pain any where, it often 
happens that at first they make no reply ; but if they are pressed, they slowly 
apply the soundlimb to the head, and in several cases it is to the side of the head 
opposite the limb whose motion is injured that they would apply the hand. This 
sign, as has been already remarked by Professor Rostan, is of the greatest im- 
portance ; it suffices almost singly, adds this learned observer, to characterise 
ramollissement. 

The cérébral substance, which may be eut and torn in iiving animais, without 
their manifesting any feeling of pain, is then capable, as well as several other 
tissues, of becoming very sensible in the morbid state. It is not here, as in 
inflammation of the lung s which is not accompanied with anything of acute pain, 
except when the pleura itself is irritated. In the cranium aîso, the acute or 
chronic inflammation of the serous membrane is accompanied by a pain, the history 
of which we have traced in another part of this volume ; but this pain manifests 
itself equally in case, where the membranes have continued perfectly sound, m 
those very cases where the softening is produced at a considérable distance from 
the periphery of the brain. Thus it is the cérébral pulp itself that becomes pain- 
ful. But why are thèse cases completely identical with respect to the seat and 
form of the softening, which differs, however, with respect to the pain, which is 
absent in one of the cases, and présent in the other ? That is a question which 
cannot be solved in the présent state of science. Let us remark only that the 
same différence is found to exist in ail the other organs, and that the most pain fui 
diseases may sometimes présent themselves altogether free from pain ; thus we 
have seen large purulent effusions into the peritoneum, suffer us, however, to 
press the abdominal parietes forcibly, without any painful sensation resulting 
from ît. 

The headach produced by softening of the brain has not always the same seat : 
sometimes it is scattered vaguely over the entire head, and cannot in any way 
indicate the point where the disease exists ; sometimes it shows itself to be sure 
in a circumscribed place, but this place does not correspond with the softening : 
thus, with several patients the forehead alone is painful, though it may be far from 
this région that the brain had lost its consistence. But observe that in a number 
of différent affections, whether of the brain or of other organs, when suffering 
reacts upon it, it is also towards the forehead that the pain is felt. There is there 
then a sort of place of élection for warning the sensibility, wherever else the seat 
of the lésion may be placed. Sometimes, in a word, the pain of head is exactly 
liniited to the point of the parietes of the cranium, corresponding to the softened 
portion of the cérébral pulp. 

With respect to the intensity of the pain of head, it is very variable : some 
patients complain but of a weight, a sort of constriction, either diffused over 
the entire cranium, or flxed to one point. In others, again, the pain is more 
acute. 

Whether the pain of head exists or not, différent parts of the body may présent 
in their sensibility several modifications. Sometimes this sensibility is diminished 
or abolished, sometimes, on the contrary, exalted. The diminution or abolition 
of sensibility is remarked particularly in the skin covering the paralysed limbs. 
In most cases this happens only when motion is already altered, but there are 
individuals, however, in whom, a long time before the appearance of the symptoms 
characteristic of softening, the extremities of the fhigers of one of the hands, or of 
the toes of one of the feet, become numbed, or cold, or are the seat of annoying 



172 



CLINIQUE MEDICALE. 



formications ; then, according as the lésions of motion are established, the sen- 
sibility diminishes more and more, and finally is extinguished altogether. 

The exaltation of the sensibility is again among the number of the phenomena 
frequently produced by softening of the cérébral hémisphères : it may be seated 
either solely in the skin or in the parts situate beneath the skin. 

Most frequently the exaltation of the cutaneous sensibility does not extend 
beyond the parts in which motion itself is altered. The skin here becomes at 
times exquisitely sensible, so that the slightest pressure produces the most acute 
pain, and sometimes occasions convulsive tvritches in the limb afFected. 

With respect to the functions of organic life, the digestion is, in gênerai, not 
disturbed ; the tongue préserves its natural appearance with regard to its colour 
and moisture ; vomiting is but seldom seen to supervene. In some cases, when 
the softening follows a chronic course, signs of gastro-intestinal irritation, more 
or less severe, are seen to occur, which soon throws the patient into a profound 
coma, and accélérâtes his death. 

The circulation is far from being always modified in the same manner in 
individuals affected with softening of the brain. The puise is in gênerai ac- 
celerated, sometimes, however, it retains its physiological state. We may lay it 
down, however, from a careful considération of the preceding cases, that the 
présence or absence of the accélération of the puise depended solely on the 
individual prédispositions, since in cases in other respects identical, it was some- 
times présent and occasionally absent. M. Rostan attaches considérable value to 
the state of the puise for the purpose of establishing a diagnosis ; it may, single 
and alone, he adds, guide us in the employment of therapeutic means, and in this 
view we entirely coincide. 

MM. Lallemand and Bouillaud have laid it down, on the contrary, as a prin- 
ciple, that inflammation of the brain, supposing it exempt from ail complication, 
exercises no influence on the circulation. 

Ont of 227 cases of softening of the cérébral hémisphères, either simple, or with 
hyperemia, or with the commencement of sanguineous effusion, or, in fine, with 
purulent sécrétion, the puise, with respect to the number of its beats, presented 
the varieties indicated in the following table : — 





TIMES. 


Puise in the normal state ... ... 


26 


Puise retarded 


15 


Puise accelerated 


72 


Puise, first normal, then fréquent ... , 


10 


Puise fréquent, then retarded ... , 


2 


Puise not noticed with respect to its frequency 


97 



With respect to the strength of the puise, it appeared very variable both in 
those cases which came under our own care, and in those published by others. 
The same may be said of its rhythm, which we found but very seldom modified. In 
the cases, however, noted by MM. Lallemand and Rostan, the puise is set down 
as being frequently irregular or intermittent. We are inclined to suspect that in 
many of thèse cases there existed an affection of the heart. 

The respiration is often influenced by softening of the cérébral hémisphères. 
It is of an affection of this function that some patients die who labour under this 
disease. The respiration may be disturbed in one or other of the three following 
ways:— 

When the progress of the softening is very acute, when it is accompanied with 
symptoms called apoplectic, the respiration is modified from the commencement, 
it is at once accelerated, and becomes stertorous, as in cases of cérébral 
hemorrhage. 

When the softening, on the contrary, h as a slow progress, the respiration at 



DISEASES OF THE ENCEPHALON. 



173 



first is not disturbed, but it gradually becomes difficult and irregular ; it is évident, 
frora observing the way in vvhich the movements of inspiration and expiration are 
performed, that the functions of the lung no longer go on as in the normal state, and 
we perceive a sort of slow asphyxia gradually take place, in which the patient dies. 

Finally, there are several intermediate cases in which the softening is neither so 
rapid nor so slow as in the two preceding séries, and where the respiration may 
still présent remarkable modifications, We have seen some individuals in whom 
the respiration, at first, was not at ail disturbed from the commencement ; then 
suddenly, without any known cause, it became accelerated and difficult ; a râle 
was heard ail over the chest, and the patients died rapidly in a state of asphyxia. 
In such cases the lésion of the nervous System suddenly exercises on the respira- 
tory apparatus an influence which was not felt at the commencement ; and it is 
by disturbing the respiration that the affection of the brain produced death. 

With respect to the duration of this disease, the inference which we are war- 
ranted in deducing, from the considération of 10.5 cases, is, that softening of the 
brain is much more frequently an acute disease than a chronic one. We see that 
very few individuals die before the second day ; the greatest number die, on the 
contrary, between the second and twelfth day. At the end of the first month, out 
of 105 subjects affected with softening, there remained more than sixteen who 
survived it ; after the second month, there remained more than ten ; after the 
third month,only seven individuals survived, and among thèse there were two who 
for three years resisted this cérébral lésion. 

Hitherto we have always supposed that ramollissement of the cérébral hémi- 
sphères terminated fatally. May it, however, terminate favourably ? In order to 
be able to answer in the affirmative, it would be necessary that the symptoms to 
which it gives rise should be so characteristic, that the mere fact of their appear- 
ance would no more allow us to doubt of the existence of cérébral softening than 
the reddened sputa and bronchial souffle allow us to doubt of the existence of 
pneumonia. The difficulties found by observers in ascertaining with certainty 
the real existence of cérébral softening have obliged M. Rostan to withhold any 
positive décision on the question, whether the brain, once deprived of its normal 
consistence, may afterwards recover it. This reserve of M. Rostan's we think 
absolutely enforced by the présent state of science ; and we do not think that M. 
Lallemand has satisfactorily proved, by the cases he has cited, that the circum- 
scribed induration of one of the hémisphères is sometimes the mark of a softening 
which has been cured. 

Death, which is the termination, at least very frequently, of this affection, may 
resuit from the mere disturbance which the softening of a part of the brain 
produces in the functions of this organ ; and we have seen that a softening of very 
limited extent was often sufficient to throw those functions into the greatest dis- 
turbance. The softening may continue for a very long time without any other 
lésion complicating it ; but, at other times, death is produced, or hastened, by one 
of thèse complications. We have already specified them. M. Lallemand's cases 
have proved that a great number of softenings might terminate, either by sanguine- 
ous effusions within the softened part, or by a sécrétion of pus which remains in a 
state of infiltration, or which coïïects into an abscess. Sometimes a hemorrhage 
takes place m a différent part of the brain from that which is softened, and it is of 
it the patient dies. In other cases, an intervening affection of the méninges 
hastens death. Again, in cases where the softening follows a chronic course, 
inflammations of différent organs, and particularly of the lungs and digestive tube, 
are added to the cérébral disease, and are the cause of death. 

If it were satisfactorily proved that softening of the brain is but one of the forms 
or degrees of inflammation of this organ, the therapeutic indications would be 
always easily established, as then the antiphlogistic treatment should in ail cases 
be adopted, caie being taken only to proportion its energy to the strength of the 



174 



CLINIQUE MEDICALE 



subject, to 1ns constitution, to the nature of the symptoms, &c. In the présent 
state of our knowledge of the nature of tins disease, we think that here, as in 
several other circumstances, the indications are furnished us less by the nature of 
the affection than by the symptoms which accompany it, and the gênerai state of 
the economy. Suppose, as often occurs, that softening of the brain is accompanied 
with ail the signs of an active hyperemia, puise strong and fu.ll, intense delirium, 
agitation, convulsive movements, rigidity, or contraction of the limbs ; in such 
cases blood-letting is indicated. Caution, however, must be observed, as we have 
known more than one case wherein repeated and large bleedings were followed 
by an exaspération of ail the symptoms. Nor are we satisfied that blood-letting 
can have any influence, except a bad one, on that species of dépression which the 
intelligence présents in several individuals affected with softening of the hémi- 
sphères. In thèse latter cases, leeches applied from time to time to the anus 
seem to us préférable to opening a vein ; they raay be applied also to the mastoid 
processes. Dry cupping towards the base of the cranium, a seton to the nape of 
the neck, révulsives on the lower extremities, seem to us the means partie ularly 
indicated. Internally, mild tonics may be serviceable ; and in the last kind of 
case we supposed, we would recommend the daily administration of the différent 
préparations of iron or quinine. Even admitting that every cérébral softening is 
an encephalitis, either acute or chrome, we would not shrink from the line of treat- 
ment we have now laid down ; for, in order to remove an inflammation in certain 
cases, and to arrest its progress in other cases, it certainly is not sufBcient to attack 
it either by blood-letting or by révulsives. It is very often necessary to support 
the vital forces to a certain standard, below which inflammation cannot be 
resolved. Much has been said, in latter times, of the tendency which many 
inflammations have to pass to the chronic state, or to disorganisation of the tissues, 
when they are not met at their commencement by sufncient blood-letting ; but, 
on the other hand, it must not be forgotten that excessive losses of blood may 
have precisely the same effect as insufncient losses. Great stress, also, has 
been laid, and with every reason, on that false state of adynamia which several 
inflammations bring after them, by the mere tact of their intensity. We entirely 
agrée in tins mode of considering the subject, so admirably developed by M. 
Broussais; but we also admit another adynamia, which is no longer simulated, of 
which the symptoms really express the failing of the strength of the System, which 
no longer dépends on the intensity of the inflammation, but rather on the condi- 
tions of innervation and hematosis, in which tins inflammation found the 'economy. 



FOURTH ORDER. 

OBSERVATIONS ON HYPERTROPHY OF THE CEREBRAL HEMISPHERES. 

This morbid change, which is somewhat rare, has hitherto but little engaged 
the attention of observers. M. Bouillaud, in his Treatise on Encephalitis, and 
Dance, in a paper, published on the subject*, are the only authors, to our know- 
ledge, who have written any thing on it ; we may add to thèse names that of 
Dr. Scoutetten, to w r hom we are indebted for a knowledge of a very remarkable 
case of this kind f . 

Hypertrophy of the cérébral hémisphères should be distin°-uished from another 
affection, in which also thèse parts are incréased in size, but by mere hyperemia ; 

* Répertoire cTAnatoinie Pathologique, publié par Brescliet, 1828. 

t Archives Générales de Médecine, tome viii. p. 31. 



DISEASES OF THE ENCEPHALON. 



175 



înconsiderable though it may be, this hyperemia produces, in the brain, as elsc- 
where, a tuméfaction of the parts where it exists. W e have given some examples 
of it, when treating of cérébral congestions ; but that is not the character of true 
hypertrophy. 

Hypertrophy of the brain should be not only distinguished from simple hyper- 
emia ; but again it should be known, that the first does not necessarily include tho 
existence of the second, and that the contrary even most frequently occurs. 
Every time that we have found in the dead body a brain really hypertrophied, 
and not merely increased in volume by hyperemia, there was at the sarne time 
remarkable paleness. The cases of Dance give the same resuit. 

It may be admitted in theory, that one of the conséquences of the fréquent 
répétition of cérébral hyperemia, may be the production of hypertrophy : let us 
remark, however, that we have not the latter lésion in a certain number of indi- 
viduals, whose bodies we examined, and who were for a long time subject to 
cérébral congestions. 

It may also be supposed, that great activity in the exercise of the cérébral 
functions may equally produce, after a time, an excess of development in the 
organ which perforais thèse functions. Are we also to présume that the hyper- 
trophy found as the sole lésion in a certain number of epileptic subjects, did net 
exist at the commencement of the disease, and was itself but the effect of the 
violent perturbation which the brain underwent, on the return of each epileptic 
attack ? 

At the same time that the brain, in becoming hypertrophied, tends to occupy a 
greater space, the bony case which incloses it may not increase in size, or else 
may become enlarged, according as the brain itself becomes developed. In the 
cases known to the présent time, the former occurrence is more frequently met 
than the latter. It follows, that in most of the cases of hypertrophy of the brain 
the latter must be subjected to an habituai compression, more or less considérable. 
We may conceive how, under such circumstances, the occurrence of a slight 
hyperemia must be more serious. Instead of producing pain of head or dizziness, 
it may give rise to the most alarming conséquences ; may bring on, for example, 
an attack of epilepsy ; in some instances may occasion death. This will be readily 
conceived, if the anatomical characters of hypertrophy of the brain be considered, 
such as we have described them in our work on Pathological Anatomy, and such 
as they will be found in the cases to be cited hereafter. 

We have not, up to the présent time, seen hypertrophy of the brain affect 
subjects more than thirty-five years old. The cases which we shall cite, and those 
published by others, relate to individuals aged from twenty to thirty years. 
However, it has been also observed in infancy. 

Hypertrophy of the cérébral hémisphères has been sometimes unaccompanied 
by any symptom ; that is, when the parietes of the cranium are developed in the 
same ratio as the brain. Such was the case of the child, as detailed by M. 
Scoutetten. This individual, about five and a half years of âge, had a head the 
size of which equalled that of an adult ; it was by degrees that it increased thus. 
The development of the cranium was much more marked behind than before ; the 
forehead was elevated, but not projecting ; ail the cérébral functions were duly 
performed ; the intelligence was suitable to the âge of the subject. It was seen 
to sleep tranquilly and profoundly. The only phenomenon presented by the child 
was the fréquent falls caused by the weight of the head, which was suddenly 
carried forward when it wished to run, and thus caused it to fall. This child died 
of acute enteritis, towards the close of which the intellectual functions were com- 
pletely abolished. 

On opening the body, it was ascertained that the parietes of the cranium were 
thicker than usual. The brain itself presented nothing more than a great develop- 
ment of ail its parts, particularly of the nervous mass situated abovethe venlricles. 



176 



CLINIQUE MEDICALE. 



The latter contained but a very small quantity of reddish sérum. The pia mater 
was very much injected, and of an opaque white in some points. The dura 
mater adhered firmly to the bones of the eranium. 

This is the only case we know in which the hypertrophy of the brain was not 
accompanied by any symptom ; and the simultaneous development of the ence- 
phalic mass, and of the parietes of the craniura, sufficiently aceounts for it. 

The symptoms which, up to the présent time, have accompanied hypertrophy 
of the brain, relate to certain disturbances of the intelligence, sensation, ai.d 
motion. 

Several patients were in a real state of idiotism ; in others we only remarked a 
dull state of the intelligence, which increased and diminished alternately ; then 
acute delirium was seen suddenly to supervene, or profound coma, and thèse two 
phenomena were soon followed by death. On one occasion, we observed signs of 
mania. 

In certain cases, a headach of long standing, which, at intervais, became worse, 
and which was reproduced under the form of violent crises, was the prevailing 
symptom. Several patients complain of vertigo, dizziness, as if they had simple 
cérébral congestion. In others, the sensibility becomes suddenly more obtuse ; 
or else a period arrives, when, after having remained a long time intact, it becomes 
suddenly abolished. 

The disturbances observed, with respect to motion, are of several kinds. Some- 
times it is mere debility of the limbs, which goes on increasing, and terminâtes in 
gênerai paralysis ; sometimes there are convulsive movements, at first infrequent, 
and not intense, then more fréquent and more severe : the patient may die in 
thèse convulsions, or in the coma which succeeds to them. At other times hyper- 
trophy of the brain betrays its existence principally by a group of symptoms 
which characterise epilepsy, the attacks become more fréquent, and death super- 
venes in the midst of one of them. 

The functions of organic life are not in gênerai disturbed by hypertrophy of the 
brain. The puise has usually its accustomed frequenc} 7 ; sometimes, however, it 
becomes slow. We have seen one case where it was only forty-five. 

The symptoms connected with hypertrophy of the brain are so arranged, that 
two periods may be reckoned from them : one, in which it présents ail the 
characters of a chronic affection ; and the other, in which it suddenly assumes 
the appearance of an acute affection. It is in the second period that the patients 
die. 

During the first period, the symptoms remarked are especially différent dis- 
turbances of the intelligence, a slight or intense headach, which is permanent or 
transient ; convulsions at intervais ; and,finally, true epileptic attacks, more or less 
repeated. Thèse différent symptoms may ail exist in one and the same subject, 
or develop themselves separately. 

After this period has lasted a longer or shorter time, the second cornes, unless 
the patient be previously carried off by the intervention of some other affection. 
Then différent symptoms and différent forms of diseases appear : thus, some 
individuals are seized suddenly with very violent convulsions, in the midst of 
which they die ; others présent the signs indicative of compression of the brain, 
or else those characterising acute hydrocephalus. Some die almost suddenly. 
The following cases, which we have collected, will serve to confirm and develop 
the gênerai propositions which have been now laid down : — 

Case 1. — Megrhn of long standing, which was succeeded by constant pain qfhead — 
At a later period, convulsive movements, whose severity, consiantly increasing, 
brought on death. 

A man, twenty-nine years of âge, of strong constitution, gave us the following 
history of himself, on entering the Maison de Santé, in Sept. 1830. At the âge of 



DISEASES OF THE ENCEPHALON. 



177 



seventeen, he began to feel a violent headach, accompanied with vomiting. This 
went ofF after twenty-four hours. Frorn the âge of seventeen years till he was 
twenty-eight, two months searcely passed withouthis experiencing the same symp- 
tonis, which were considered by him and by those who saw him, as attributable to 
megrim. When he had it not, he enjoyed very good health. It was only about 
a year previous to his being submitted to our care that thèse symptoms, which 
had not appeared up to that period of any importance, assumed a more serious 
character. He then began to feel constantly a pain, which occupied the entire 
head, but more particularly the frontal région and the two temples. This pain, 
usually dull, became, from time to time, very intense ; then the patient shunned 
the light, pressed his head with his hand in order to relieve himself, and remained 
very quiet. Six months after this headach commenced, he was seized one day, in 
the two arms, with involuntary movements, and convulsive twitches, which he 
could not resist, and which were accompanied with an acute pain in the con- 
vulsed limbs. This new scène of phenomena lasted for some hours. When the 
convulsions ceased, the patient remained very much fatigued, and, dating from 
this time, he was weak and languid ; he always felt as if exhausted by running a 
very long journey. He was averse to moving, and every morning, on awaking, 
he felt himself quite harassed. Pain of head continued, and became more intense. 
During the six months preceding his admission to the Maison de Santé, he felt 
five or six times, in the two upper extremities, the sarne convulsive movements. 
In fine, thèse movements became ail at once much more intense, and at the same 
time much more fréquent. During the eight days preceding his admission, they 
were nearly constant, and began to attack also the lower extremities, and more 
particularly the left. 

When the patient was first examined by us, he looked like a man worn down 
with fatigue ; he was able, however, to state, with ease and précision, ail the 
détails we have now given : he had not at that time any convulsions, and could 
not speak of their return without a degree of terror. The pain of head was now 
moderate, on the preceding day it had been most violent. The sensés presented 
no altération. Puise natural ; appetite considerably diminished for some time 
back. 

We were very much puzzled to form a diagnosis of such an affection ; it had in 
its symptoms something unusual which did not appear to be connected with any 
of the known cérébral lésions. What was in particular the cause of those inter- 
mitting convulsions, in the intervais of which motion remained perfectly free, and 
which, for a long time confined to the upper extremities, commenced some time 
back to become gênerai, and to extend to the lower îimbs '? If the patient had 
not presented that pain of head so remarkable for its long standing, its continu- 
ance and its periodical exaspérations, we should have thought that the spinal marrow 
was the source, whence ail thèse symptoms derived their origin ; but whilst in 
placing in this marrow the seat of the lésion, we could not well pronounce an 
opinion on its nature, it seemed to us that the différent symptoms we observed 
might dépend on the existence, within the two hémisphères, of accidentai pro- 
ducts slowly developed. Were they tubercles ? We hesitated to admit it, recol- 
lecting the law laid down by M. Louis, and the truth of which we so often proved, 
according to which tubercles are rarely found in other organs, except when they 
have been in the lungs. Now in this person the respiratory apparatus appeared 
perfectly sound. 

Such were our reflections on the case of this patient, and the hypothesis we 
assumed regarding the nature of his complaint were far, as we shall see, from 
representing the truth. 

However, the days following, the patient presented a déplorable state. The 
pain of head became more intense than ever : it was so violent that the patient 
made the ward resound with his groans and cries. This attack lasted during two 

N 



178 



CLINIQUE MÉDICALE. 



or three hours ; then the pain diminished, without ever entirely disappearing, and 
at this time the patient, as if worn out by his sufferings, remained immoveable, 
without however being able to get any sleep. Once or twice a day, he felt, both 
in the upper and lower extremities of the right and left side, twitches which were 
painful, but of short duration ; occasionally also the muscles of the face were 
affected by some convulsive movements. In the midst of ail thèse disturbances, 
the intelligence remained intact, and the puise was fifty-five. 

Nine or ten day s passed on in this way, at the end of which time the con- 
vulsive movements became suddenly much more violent ; the face and four 
extremities were simultaneously the seat of them ; after having lasted almost 
without interruption for thirteen hours, they ceased suddenly ; but nearly at the 
same time the respiration became embarrassed, it became stertorous, as in 
apoplectic patients, and the patient died rapidly. 

Post mortem. The méninges presented nothing extraordinary. The external 
surface of the brain struck us by its very singular appearance : the spaces sepa- 
rating the circumvolutions had disappeared ; the latter were compressed, and as it 
were squeezed together ; they evidently acquired a greater development at the 
expense of the anfractuosities. Not a drop of sérum in the arachnoid or pia 
mater, nor in the latéral ventricles, the parietes of which touched and pressed 
each other much more than natural. The nervous substance itself presented two 
remarkable changes with respect to its colour and its density : its colour was so 
changed that at its circumference the grey layer of the circumvolutions was 
scarcely any longer distinguishable from the subjacent white substance. The latter 
itself is everywhere bloodless ; on cutting it we do not perceive the orifice of any 
vessel, nor can we distinguish the least drop of blood in the slices that are taken 
from it. The grey substance scattered on the interior of the hémisphères, more 
particularly that entering into the composition of the optic thalami and corpora 
striata, was colourless as the grey substance of the circumvolutions. Through 
the entire extent of thèse hémisphères, the substance constituting them attained 
extraordinary density ; it resembled the white of an egg hardened by boiling ; it 
has the same consistence and the same elasticity also. 

Remaries. — The anatomical characters of hypertrophy of the brain are very 
well marked in this case. The increase of density hère coincided with the 
increase of volume, as was satisfactorily proved by the total effacement of the 
anfractuosities ; the blood also had really fled from the cérébral substance, so 
that there was here a coincidence of hypertrophy and anémia. 

Is the headach, in such a case as this, the resuit of the compression to which 
the nervous substance was subjected ? It was for a long time the only symptom, 
At the time it was considered as a simple megrim. Did it already announce the 
commencement of the cérébral lésion ? If so, the latter was formed very slowly, 
and a long time elapsed before it produced serious symptoms and compromised 
existence. Thèse symptoms principally affected motion and respiration. The 
intelligence continued constantly intact, whilst, on the contrary, it was disturbed 
in the following case. 

Case 2. — Graduai weahening of the intelligence — Epilepsy — Pai?i of head of long 
standing — ÎDeath in the midst of an attacJc. 
A female, twenty-seven years of âge, was epileptic from the âge of twelve 
years, when she entered the hospital Cochin. From the âge of twelve up to 
nineteen, the period at which she menstruated for the first time, she had an attack 
cf epilepsy every three or four months nearly. The appearance of the menses 
did not cure her ; on the contrary, from this period the attacks became more 
fréquent ; three weeks did not pass without the occurrence of one. Towards the 
âge of twenty-one, she began to feel at intervais a violent pain of head, which she 
called megrim ; it returned about every six weeks or every two months, and was 



DISEASES OF THE ENCEPHALON. 



179 



neither preceded nor followed by the epileptic attack, with which it really did not 
seem to hâve any connexion. Up to the âge of twenty-four, this vvoraan thus 
continued subject to the two affections which \ve have just mentioned. In the 
intervais between her crises of headach, and the attacks of epilepsy, she presented 
no disturbance of intelligence, sensation, or motion. The menses came regularly 
every month ; but between the twenty-fourth and twenty-fifth year, the disease 
changed its aspect : the headachs were no longer so violent ; they no longer 
returned under the form of crises ; but the patient began to feel habitually a dull 
sort of pain of head, principally seated towards the forehead, which consisted in a 
feeling of weight ; the attacks of epilepsy became more and more fréquent, and 
at the same time the intelligence, till then intact, began to be altered. At first 
this woman's temper became very strange ; there was observed something singular 
in her conduct and manner, which caused those who usually saw her to say that 
she was becoming mad. However, this modification of the intelligence was not 
of long duration, and soon, instead of being perverted, it was only weak. Insen- 
sibly this woman fell into a sort of state of imbecility, at the very highest stage 
when she was admitted into our wards at the Hôpital Cochin. From thence she 
was removed to the Salpetrière. We learned ail the history of the case from her 
relatives. They further told us, that for the last year she had not passed three 
days without having an attack of epilepsy, and that often she had several of them 
in one day. The menses had ceased to appear for the last six months only. On 
our examining her, we could only discover weakness of intellect ; the power of 
motion was free ; sensibility not affected. The fonctions of the life of nutrition 
did not seem to have undergone any perceptible change. 

During the five days following the patient had, almost every day, an attack of 
epilepsy, which we did not witness. On the sixth day, dating from her admission, 
we found her dead in her bed. According to the account of the attendants, she 
had been attacked, during the night, with a very violent attack, which was followed 
by a profound stupor, in which she died. We satisfied ourselves, however, that 
the attacks were epileptic. 

Post mortem. We had scarcely raised the arch of the cranium, when we were 
struck with the singular tension presented by the dura mater. It was very much 
pressed from within outwards by the substance of the brain. When we eut into 
it, we discovered the two other méninges, of which the one, namely, the arachnoid, 
was, at its free surface, remarkably dry, and of which the other, the pia mater, 
entirely deprived of sérum, was traversed by some veins containing a very little 
blood. Thèse two membranes were torn with very great facility. Beneath them 
the external surface of the brain had a singular appearance. No anfractuosities 
were any longer distinguishable there, so much were ail the convolutions pressed 
one against the other. The nervous substance, through the entire extent of the 
hémisphères, was remarkably pale ; scarcely could the grey substance be distin- 
guished from the white by the colour. This substance had also attained in every 
part great density ; in most of the parts, where it was examined, it was found 
similar, as in the preceding case, to white bf egg hardened by boiling ; in some 
this pulp had really the consistence of a cartilage. The ventricles were really 
empty of sérum. The corpus callosum, fornix, and septum were also increased in 
density ; on the contrary, the pons Varolii, cerebellum, and the spinal marrow 
had their natural consistence. 

Remarks. — This case, compared to the preceding, resembles them very much 
with respect to the anatomical lésions ; and yet, in certain respects, the symptoms 
are not the same. The two individuals were equally subject to an intense headach ; 
in the first, it was, for a long time, the only phenomenon : in the second, it alter- 
nâtes with epileptic attacks. The latter replace the simple convulsive movements 
in the subject of the second case ; in her, the disturbance of intellect was very 
rnarked, whilst in the other, the intellectual faculties preserved ail their intelligence. 

x 2 



180 



CLINIQUE MÉDICALE. 



Case 3. — Graduai debility of the intelligence, motion, and sensation — Convulsions- at 
intei'vals, ivith loss of consciousness — Death in an adynamic state. 

A countryraan, thirty-nine years of âge at the time of bis entering the hospital 
La Pitié, commenced to feel, for about ten years before, pains of head, which 
returned at intervais, some of them being accompanied with confusion in his ideas. 
One day, the pain of head returned with more violence than ever, and, after 
having béer, tormented for three or four hours, he was seized with strong convul- 
sions, and he soon fell, deprived of consciousness. At the end of a little time, fie 
came to himself ; but, dating from this moment, he no longer recovered his usual 
intelligence ; he had less memory, he was no longer capable of any employment, 
and he was obliged to give up his situation. During the following years, the 
intelligence became weaker and weaker, and, at the same time, the muscular 
strength gradually diminished, as also the sensibility. At intervais, this rnan sud- 
denly lost consciousness, and he was seized with convulsive movements in the four 
extremities. 

After having been a long time in the hospital of the country where he lived, 
he was brought to me, and I received a written note, containing the preceding 
détails ; for he was himself incapable of giving any. 

When I saw him, I could scarcely force from him the most vague answer ; 
a continuai air of abstraction was imprinted on his countenance : he was observed 
to laugh and cry without any motive : he scarcely knew whence he came or where 
he was. When asked whether he felt pain in any part, he pointed towards his 
forehead. Cutaneous sensibility very obtuse. It was with considérable difficulty 
he could sustain himself on his legs, which were staggering, and from time to time 
were taken from under him ; they both seemed equally weak. A constant 
trembling agitated the upper extremities ; and the two hands could neither of 
them hold any thing ; vision was intact, as well as the other sensés ; he did not 
however appear to perceive smells : puise 56 ; digestion good ; the respiration 
tranquil. 

This patient was admitted into one of the wards of the La Pitié. 

During the three first weeks he was in the hospital, nothing new presented 
itself about him ; only at three différent times he lost consciousness, and had con- 
vulsive movements ; thèse circumstances were seen only by the sister of the 
ward. This man, who was remarkably taciturn, rernained immoveable in his bed, 
and they were obliged to watch him as a child. During the fourth week of his 
stay, a large eschar commenced to form on the sacrum ; the tongue became dry ; 
teeth black ; faeces and urine possed involuntarily ; death five weeks after his 
admission. 

Post mortem. The cérébral hémisphères presented in their circumference the 
same appearance as in the two preceding cases : there was here the same packing of 
the circumvolutions, the same effacement of the anfractuosities, the same hardening 
and paleness of the nervous substance ; in fine, the same dryness of the enveloping 
membranes. As in the other cases, the cerebellum, pons, and spinal marrow were 
not affected. 

Remarks. — Here again we find symptoms very much resembling those presented 
by the two preceding cases, but they are combined and connected differently. 
The first phenomenon which appeared, was a headach, which returned occasionally, 
and which was not connected with any other serious symptom ; then suddenly 
there came on other phenomena, which have at least some resemblance to those 
characterising epilepsy, and dating from this period, the intelligence, hitherto 
intact, became disturbed, and gradually weaker. Anatomy really shows us but 
the last term of the disease, and does not reveal to us ail the shades or ail the 
degrees through which the altération must pass, from the moment when it evinced 



DISEASES OF THE ENCEPHALON. 



18' 



its existence only by.a transient pain of head, to that when serious disturbances 
attacked simultaneously intelligence, motion and sensation. What, for example, 
was the change, which came on suddenly in the brain, the day when, with equal 
suddenness, the patient was seized for the first time with an epileptiform attack ? 
Did hypertrophy of the brain already exist at this period 2 Was there as yet but 
mere cérébral congestion ? Did this congestion ever exist at any period of the 
disease ? This congestion, w hich is so convenient to serve as a means of explain- 
ing a great number of cérébral disturbances, is it as common as we imagine ? We 
would have a right to doubt it, if we reflect that, in many of the cases, where the 
symptoms which we attribute to it had existed during life, anatomy shows us 
no sign of it. It is certainly from views altogether hypothetical, that we con- 
stantly make it corne in to explain, ekher most of the disturbances of organisation, 
or many functional disturbances. 

Here are there cases where the brain is the seat of an altération precisely similar. 
Why was the intelligence disturbed in the two latter cases ? Why did it remain 
intact in the first ? 



FIFTH ORDER. 

OBSERVATIONS ON ATROPHY OF THE CEREBRAL HEMISPHERES. 

We have elsewhere pointed out ail the degrees of this atrophy, from that 
wherein the hémisphères are completely wanting, to that wherein some circumvo- 
lutions are absent, or incompletely developed. We shall here direct our attention 
particularly to those cases of atrophy, which are compatible with the possibility 
of an extra-uterine life more or less prolonged. 

Thèse cases are those wherein there is atrophy or want of development, either 
total or partial, only in the nervous mass situate above the ventricles. 

We have not seen any case, in which the complète absence of this nervous 
mass of the two sides coincided with the prolongations of life, beyond a small 
number of months after gestation ; but authors have cited examples of it, and in 
thèse cases it was merely végétative life which took place. 

When atrophy exists only in one side, life may continue for a very long time. 
We have seen cases of this kind : above the latéral ventricle of one side, there was 
no longer found any nervous substance ; the arachnoid, usually covering the con- 
vexity of the hémisphères, was found in apposition to that which should line the 
parietes of the ventricles ; thèse two folds, of one and the same membrane, were 
separated from each other by a cellular tissue, provided with a great many vessels. 
Sometimes, in such cases, the cranium préserves its natural form and dimensions ; 
then a great quantity of sérum raises the arachnoid, and also fills the vacuum, 
which would exist without it, between the cranium and remaining parts of the 
hémisphères ; sometimes the form of the cranium is changed ; its parietes are as 
it were sunk in the points which correspond to atrophy of the brain ; and during 
life, we find on one of the sides of the cranium, a greateror less dépression, which 
may assist in the diagnosis. Here is a remarkable example of the first of thèse 
two cases. 

Case 1 . — Absence of the entire nervous mass situate above the right latéral ventricle, 
with the exception of the part of this mass anterior to the corpus strialum — Normal 
conformation of the cranium — Lésion of motion in the left extremities — Integrity 
of intelligence — Pulmonary tubercles. 

A man, twenty-eight years of âge, fell, when three years old, from a first story 
into the street : he fell on his head. After this fall he rcmained paralysed on tbe 



182 



CLINIQUE MEDICALE. 



left side. By degrees an habituai extension of the left foot on the leg was 
established, so that, on the left, he walked only on the point of the foot. The left 
upper extremity was completely deprived of motion ; no trace of contraction any 
where observed. This person had received some education s and had profited by 
it ; he had a good memory ; speech perfectly free ; and his intelligence such as is 
ordinarily met with in the generality of persons. Having entered the infirmary 
of Bicêtre, where he lived, for a chronic affection of the chest, he was there seized 
with symptoms of acute peritonitis, of which he died. 

Post mortem. The vault of the cranium having been removed, the méninges of 
the right side were found transparent, and fluetuating through almost their entire 
extent. They were eut into, and a clear, limpid sérum, like rock water, gushed 
forth. Between thèse méninges and the ventricles, there existed not the slightest 
trace of nervous substance ; thèse membranes constituted the upper wall of an 
immense cavity, the lower wall of which was formed by the optic thalamus, the 
corpus striatum, and ail the other parts situate on the level of thèse two bodies. 
Of the nervous mass situate above the ventricles, there remained only that which, 
situate anteriorly to the corpus striatum, forms its anterior wall. Numerous tuber- 
cles traversed the two lungs, and several ulcérations appeared on the surface of the 
small intestine. There was a perforation in the ileum, whence the peritonitis, 
which terminated the life of the patient. 

Remarks. — The lésion, discovered in this case, commenced to be formed after 
an external force, twenty-flve years before the period when it was examined by 
us. The atrophy of the brain was not probably here the primitive altération : it 
succeeded to other altérations of an inflammatory nature, which went on to form 
immediately after the fall. 

The perfect préservation of the intelligence up to the last moment is certainly 
a remarkable circumstance in a case where so great a portion of the brain had for 
a long time ceased to exist. 

In a similar case, quoted by M. Breschet, which refers to a child four years 
oid, the intelligence was, on the contrary, very much altered : the child was com- 
pletely idiotie ; it was dumb, though not deaf ; and could not sustain itself on 
its legs. 

It more frequently happens that we find atrophy of only a smaller portion of 
the nervous mass situate above the ventricles. In this case it is most commonly 
in one of the anterior lobes that the defect of development exists. Separate 
atrophy of this lobe has been seen at ail âges, from commencing infancy to 
advanced old âge. The following is an example of it, observed by us on an indi- 
vidual seventy-one years old : — 

Case 2. — Hemiplegia of a long standing— Obtuse slate of the intelligence, great 
difficulté/ in speaking — Atrophy of the anterior lobe ofthe left hémisphère. 

A man, seventy-one years of âge, entered the La Pitié in a complète state of 
childishness. We could obtain no information regarding his previous history. 
We ascertained in him the existence of a complète paralysis, both of motion and 
sensation, of the right side of the body ; he stammered out some unintelligible 
words. This man gradually became weak, and died about a month after his 
admission. During the last eight days of bis life, we observed that he coughed, 
that his respiration was embarrassed, and his tongue had become dry. 

Post mortem. The left hémisphère in its anterior fourth was replaced by a 
cyst with transparent parietes, filled with limpid sérum ; one very thiu layer of 
nervous substance séparâtes it from the corpus striatum ; thus it does not imme- 
diately form the wall of the ventricle. The left lung was in the state of red 
hepatisation throughout its entire extent. 

Remarks — There was hemiplegia in this case, though the lésion had attacked 
only the anterior part of one hémisphère, and the intelligence was disturbed, 



DISEASES OF THE ENCEPHALON. 



183 



though the atrophy was much less considérable than in the subject of the first 
case, where it remained intact. 

M. Breschet has published the remarkable case of a girl, fifteen years of âge, 
in whom the two anterior lobes were wanting. At the bottom of, and behind, 
the membranous pouch which replaced them, the two corpora striata were seen 
exposed. The head was very well formed. 

This girl was plunged into a complète state of idiotcy ; it was necessary to 
dress her and feed her ; she was reluctant to walk, though she had the power of 
moving the four extremities with ease and with equal facility ; she was usually 
sitting, and remained so for entire days, alternately inclining the head from one 
shoulder to the other ; vision was intact ; the most perfect indifférence existed for 
agreeable or disagreeable odours. 

Here was a case where atrophy of the two anterior lobes did not bring on 
paralysis, properly speaking. Neither did this paraïysis exist in two other sub- 
jects, who were still younger, for a knowledge of which we are also indebted to 
M. Breschet. 

In one of thèse cases the individual, nineteen months old, was able to move his 
four extremities with ease, only there was observed in him an almost continuai 
flexion of the trunk backward : this child was deprived of sight ; after having 
remained for about four months in this state of opisthotonos, he was seized with 
convulsions, of which he died. 

Ail the mass of the hémisphères situated above the ventricles was less deve- 
16ped than usual ; anteriorly it was completely wanting on both sides, and in its 
place ail that was found were the méninges raised by a great quantity of sérum. 
The head was in every other respect well-formed, only it was somewhat large. 

In the other case the child, twenty-two months old, also had the cranium well 
formed : he was affected with strabismus ; motion and sensation were perfect. 
This child died of a gastro-enterite. The same altération of the brain was found 
in him as in the preceding. 

Beside thèse cases, in which the absent nervous substance was replaced by 
sérum in greater or less abundance, other cases may be cited in which this sérum 
no longer existed, and where ail that was observed was a greater smallness in the 
différent parts of one of the hémisphères, and particularly of the circumvolutions. 
This species of atrophy seemed to us sometimes primitive and truly congénital, 
sometimes consécutive to, and developed after a number of diseases. There are 
some cases of this kïnd published by M. Casauvieilh, in his interesting paper on 
cérébral agenesy*. 

The persons whose cases he cites, aged from twenty-seven to sixty-eight years, 
were ail affected for a great number of years back with lésions of motion on one 
side of the body (hemiplegia, simple or with contraction), and their intelligence 
was more or less obtuse. The extremities opposite to the atrophied hémisphère 
had, in their différent dimensions, less development than the others. 

Instead of an atrophy affecting but one of its hémisphères, the brain may pré- 
sent, in the right and left, at one and the same time, in several of its parts, an 
arrest of development considérable enough seriously to interfère with its functions. 
This gênerai atrophy of the brain existed in a remarkable manner in an epileptic 
patient, whose case is recorded by M. Calmeil-f\ 

In the cases recorded by M. Casauvieilh, the lésion of motion was more 
developed than that of intelligence. The same also occurred in the following 
case, seen by us some years since at the La Charité. 

* Archives Générales de Médecine. 

f Journal Hebdomadaire de Médecine, tom. i. p. 225. 



184 



CLINIQUE MEDICALE. 



Case 3. — Forty-seven years of âge — Hemiplegia of long standing — Intelligence a 
little weakened — Atrophy of one hémisphère, with hardening of its substance — 
Death by pneumonia. 

A man, forty-seven years of âge, was paralysed in the entire of the left side of 
the body, when he was admitted into the La Charité under the care of M. Ler- 
minier. This paralysis had existed ail his life : he had not, at least, any recollec- 
tion of when it coramenced ; ail he said was, that in his ehildhood he could not 
use his extremities of the left side. There was no trace of contraction ; the limbs 
deprived of motion were manifestly thinner, but shorter than those of the opposite 
side ; the skin covering them had preserved ail its sensibility. The intelligence 
appeared to be a little weak ; however, he possessed his reason, and could join in 
a connected conversation ; the functions of the life of nutrition were duly per- 
formed. This man was seized suddenly with symptoms of acute pneumonia, of 
which he died. 

Post mortem. The cranium was considerably depressed in the entire of the 
right side. We had not observed this dépression during life. On the right, also, 
it has less extent in its différent diameters, and its walls are manifestly thicker 
than on the left. The méninges présent nothing remarkable ; the two hémisphères 
are différent in size : the right evidently smaller than the left. This greater 
smallness evidently dépends on the shrivelling which the middle lobe had under- 
gone, the tissue of which was, at the same time, remarkably dense. The optic 
thalamus and corpus striatum of the right side, are much smaller than the same 
parts on the opposite side. The right latéral ventricle contains more sérum than 
the other, and is also larger. The left lung in a state of red hepatisation, in the 
two-thirds, at least, of its extent. 

Remarks. — Was the change, of which the right hémisphère was the seat, in this 
subject congénital ? It may be supposed so. It had left intelligence and sensa- 
tion almost intact ; motion alone was seriously compromised, and, in the paralysed 
limbs, nutrition was less active, as was proved by the commencement of atrophy 
in thèse limbs. What was the cause of this atrophy ? Was it merely the vvant 
of exercise on the part of the muscles ? Was it a less action of the brain on the 
nutrition of the parts, and this fact may serve to prove the influence exercised on 
nutrition by the nervous System ? In fine, the same cause which, in the fœtus, 
had produced in one of the sides of the brain an arrest of development, had it 
interfered, at the same time, with the évolution of the limbs opposite to the 
atrophied hémisphère ? 

There was here but simple paralysis : in other cases, where the lésion was pre- 
cisely similar, the limbs deprived of voluntary motion were, at the same time, 
contracted. The same phenomena were presented by some of the cases of M. 
Casauvieilh. We saw this exist, also, in the patient of Bicêtre, whose case has 
been already detailed. This may also be seen in the following case recorded by 
M. Boulanger : — 

A child, two years old, experienced a constantly increasing difficulty in moving 
the extremities of the right side : there supervened a state of permanent contrac- 
tion of thèse limbs, and particularly of the upper extremity of the right side. The 
right fore-arm very much contracted on the arm, and it cannot be extended without 
causing pain. He complains of a fixed pain in the left pariétal région ; the intel- 
lectual facvdties are sound ; he speaks very well, likes to play and converse. He 
arrived at the âge of four years, and then died of pneumonia. 

On opening the body, the anterior lobe of the left hémisphère was found, as it 
were, depressed by afurrow which iv as fille d by a serons infiltration of the pia mater 
(thèse are the author's own words). The circumvolutions were pressed inwards, 
changed to a black and yellowish colour ; the septum lucidum did not exist. 



DISEASES OF THE ENCEPHALON. 



185 



It is to be remarked here, that the altération of the right hémisphère did not 
here consist in mere atrophy of its substance ; the latter in those parts where it 
had less volume, presented at the same time a remarkable change of consistence. 
Was there then a compression and heaping together of the molécules of the 
nervous tissue, rather than a real lessening of their number ; and was the atrophy 
but apparent? The third case of M. Casauvieilh présents, in this respect, a 
similar phenemenon, that is, coïncidence of a smaller volume and greater density ; 
but in several other cases of his, \ve see thèse two lésions no longer go together ; 
the consistence is normal, and yet the nervous substance does not occupy the 
space it should ordinarily fill. 

When the atrophy is still more inconsiderable or more gênerai than in our case 
and in those of MM. Casauvieilh and Boulanger, the intelligence becomes in its 
turn more seriously disturbed ; it is usually abolished, and the individuals are 
born idiots, or become so. The following case is in support of this opinion : — 

Case 4. — Seven years — Idiotcy — Epileptic convulsions — Pulmonary tubercles. 

In the year 1821, there was in the Hôpital des Enfans, under the care of M. 
Jadelot, a little girl seven years old, who, from birth, had not given the least sign of 
intelligence. The two lower extremities were much more slender than might 
have been expected from her âge ; no voluntary motion could be impressed on 
them by the patient, who remained constantly lying down ; the upper extremity 
of the right side was habitually the seat of strong contraction. This child did not 
speak, and it presented ail the traits of complète idiotcy ; from time to time it was 
seized with convulsive movements, which bore considérable resemblance to the 
convulsions of epilepsy ; she died of pulmonary phthisis. 

Post mortem. The cranium had, more particularly anteriorly, much smaller 
dimensions, than what is usually seen at the âge of this individual. 

A copious serous liquid infiltrated the pia mater over the entire convexity of 
the hémisphères ; this liquid had put an interval of several lines between the 
arachnoid and brain. 

The circumvolutions, on the right as welî as on the left, but more anteriorly 
than posteriorly, were remarkable for their small share of development, and at 
the same time for the smallness of their number ; they were shrivelled, and as it 
were, decayed ; the resuit of this was, that on the différent points of their con- 
vexity, the cérébral hémisphères did not présent a surface, which had every where 
the same level : this surface was on the contrary singularly uneven ; it presented 
a séries of élévations, few in number, and of dépressions much more numerous. 
In most of the dépressions the nervous tissue was very dense ; it had even in some 
parts a cartilaginous consistence. The latéral ventricles were very large and fllled 
with a great quantity of limpid sérum. The optic thalami and corpora striata were 
very small ; it was particularly on the left, that this defect of development was 
remarkable : and on this side the optic thalamus was ail unequal and wrinkled. 

Remarks. — This case présents us, with respect to motion, the same disturbances 
as the preceding ; to this is added a very serious disturbance of the intelligence, 
which is amply accounted for by the greater degree of cérébral atrophy, and its 
existence in both hémisphères. The contraction of the right upper extremity is 
conformable to the greater atrophy of the optic thalamus and corpus striatum on 
the left than on the right. In thèse cases of atrophy, as well as in the cases of 
hypertrophy previously quoted, the cerebellum is unconnected with the brain ; 
to no purpose does the latter undergo the most perceptible modifications in its 
size ; the other is not influenced by it, at least in the generality of cases ; for 
among the cases of M. Casauvieilh, there is one where we see the hémisphère of the 
cerebellum participate in the atrophy afFecting the cérébral hémisphère of its side. 

In the case now cited, the latéral ventricles were remarkable for their extrême 
size, which contrasts with their diminution or effacement, so perceptible in the 
cases of hypertrophy above detaiied. 



186 



CLINIQUE MÉDICALE. 



SIXTH ORDER 

OBSERVATIONS ON CANCER OF THE BRAIN. 

This affection, characterised by the existence, within the nervous substance, of 
new products, known by the name of schirrus and encephaloid matter, is rather 
rare. The remarks whieh we shall présent on it are founded on the analysis of 
forty-three cases, some of which belong to ourselves, whilst the others are 
scattered through différent médical works. 

In thèse forty-three cases, the cancer had not always for its seat the cérébral 
hémisphères themselves ; thirty-one times it affected thèse hémisphères ; three 
times the pituitary gland ; five times the cerebellum, once the pons varolii ; and 
three times the spinal marrow. 

The size of the cancerous masses developed in the nervous centres is far froni 
being always the same ; there are some cases where one entire hémisphère was 
transformée! into a cancer ; there are others where the accidentai product scarcely 
equals the size of a nut. 

This number is equally variable ; sometimes there is but one ; sometimes several 
are found, which occupy différent points of the encephalon. 

Around thèse cancerous masses, the nervous substance présents an appearance, 
which is far from being always identical. There are some cases where it présents 
ail the conditions of its normal state ; there are others where it is altered, either 
simply injected in différent degrees, or hardened and more frequently softened. 

When the cancer affects the periphery of the brain, it may attack the méninges 
and destroy them ; it may again extend its ravages to the bony structure itself. 
Cases have been seen where it completely destroyed the temporal and frontal bones ; 
others have been seen, where, after having perforated the crebriform plate of the 
ethmoid bone, it penetrated into the nasal fossse, and filled the différent sinuses 
which communicate with thèse cavities. In one case the cancer developed on the 
side of the lower surface of the brain, escaped from the cranium, sending ramifica- 
tions through the foramina of its base. 

When the cancer is situated so as to touch the nerves, it seldom leaves them 
intact ; sometimes they also undergo the cancerous dégénérescence ; sometimes 
they are compressed or destroyed by the tumour which surrounds them. 

Among the forty-three cases included in our analysis, there were ten in which 
the cancer, of which the nervous centres were the seat, had also attacked other 
organs. In none of thèse ten cases does the brain appear to have been the primary 
seat of the disease, and différent parts must already have been attacked by it, so 
that the nervous centres may be affected in their turn. Sometimes also the brain 
becomes cancerous, onîy after a cancer had been removed from some part. There 
was a remarkable case of this nature lately in the wards of the La Charité, in the 
words of MM. Boyer and Roux : — A man reeeived a blow on the testicle : this 
organ remained tumefied, and painful, and rapidly underwent the cancerous dégé- 
nérescence ; it was removed. Up to the moment of the opération ail the other organs 
appeared intact. The diseased testicle was scarcely removed, when, ail at once, 
this man, who had hitherto enjoyed a tolerable good state of health, wasted away 
rapidly ; he died, and on opening the body, enormous cancerous masses were 
found in ail the lymphatic ganglia of the mesentery, in the liver, in the spleen, in 
the lungs, and finally in the brain. 

Thus, in this case, external violence acts as a purely occasional cause to 
develope in the part accidentally irritated, a lésion to which the economy was 
predisposed ; without this prédisposition, it would not have produced it. ïrame- 
diately cancers sprout up from ail parts ; there is no longer a necessity, in order 



DISEASES OF THE ENCEPHALON. 



187 



to give rise to them, for an external irritation, similar to that which h ad acted on 
the testicle ; but, what is remarkable, this diathesis does not appear, or, at least, 
the symptoms do not betray it to us, until the organ is removed, in which the 
cause of the cancer seemed to be enclosed. 

The causes under the influence of which the cancer of the brain is deve- 
loped are not better known than those which produce it in the other parts of 
the body. There, as elsewhere, a pre-disposition must be admitted, without 
which the occasional causes remain without influence. Thèse occasional causes 
themselves are not appréciable, except in a very small number of cases. Thus, 
out of forty-three cases, there were but two in which the cancer of the brain 
succeeded to external violence, to which the cranium had been subjected. In 
none of thèse cases did it develope itself after an acute disease of the brain, 
or of its envelopes. 

Cancer of the brain has been observed at the most différent periods from 
the âge of two years up to that of seventy-seven. Here is what our forty-three 
cases présent to us in this regard. 

Before the âge of twenty years, eight cases of cancer of the encephalon were 
observed of which 

2 cases were at - - 2 years. 1 case was at - - 11 years. 

1 - - - - 3 1 ... 14 

1 - - - - 4 1 - 17 

1 - - - - 7 

From twenty to thirty years, we know of but two cases, one of which regarded a 
subject aged twenty-one years, and the other an individual aged twenty-nine years. 
From thirty to forty years, we find eight cases distributed as folio ws : 

2 cases at - - 33 years. 2 cases at - - 37 years. 
1 - - - - 34 2 - - - - 38 

1 - - - - 36 

From forty to fifty years, we find eleven cases distributed as follows : 

1 case at - 40 years. 3 cases at - - 47 years. 

I - - - - 41 2 - - . - 48 

3 - - - - 45 1 - . . . 50 
From fifty to sixty years, we find nine cases distributed as follows : 

1 case at - - 51 years. 1 case at - 57 years. 

3 - - - - 52 3 - ... 58 

1 - - - 55 

From sixty to eighty years, we find five cases distributed as follows : 

1 case at - - 62 years. 1 case at - - 71 years. 

1 - - - - 64 1 - ... 77 

1 - - - - 66 

In the same manner as ail the other accidentai products developed in the brain, 
cancer does not reveal its présence by any characteristic symptoms. According to* 
its situation, size, state of the nervous substance around it, and in a word, accord- 
ing to the manner (and that is altogether vital) in which the brain is affected byits 
présence, this morbid product is accompanied by différent phenomena, and it is much 
less by their own nature than by their mode of appearance and connection, and by 
the ensemble of the circumstances of the disease, that we can establish a diagnosis. 

Thèse phenomena may regard the intelligence, motion, sensation, and the 
différent acts of organic life. 

The altérations of intelligence are by no means constant : far from it, in the 
greater number of cases observed up to the présent time, the intelligence has 
remained intact. In others, it is disturbed only in the latter period of the disease. 



188 



CLINIQUE MÉDICALE. 



Tliere are cases also, where it is but at intervais more or less remote that the intel- 
lectual faculties become impaired : the individuals affected présent from time to time 
either an obtuse state of the intelligence, or a gTeater or less loss of memory, or a 
true deliriuin. In fine, sorae of the individuals, in whose brain cancer has been 
Jiscovered, have been affected with lunacy. 

Neither are the lésions of motions more constant than those of intelligence ; they 
have been found absent in more than one case. When they do exist, which is the 
most common case, they generally Consist in a paralysis which is established 
gradually. Sometimes this paralysis is partial, simple hemiplegia, or else para- 
plegia. This latter species of paralysis took place in a remarkable case cited by 
M. Esquirol, whether each anterior extremity of both hémisphères vras occupied 
by a cancerous mass. 

This paralysis may be simple, or complicated with contractions, either continu- 
ally, or at intervais. 

In several cases, convulsive movements, sometimes partial, sometimes gênerai, 
corne on at intervais. 

Finally, in more than one case the existence of attacks of epilepsy has coincided 
with the development of a cancer in différent points of the encephalon. Thus the 
further we advance, the more we see epilepsy show itself in connexion with lésions 
the most différent, but belonging exclusively to none. 

The lésions of sensation are as variable as those of motion and intelligence. — 
Thus the pain of head, though fréquent, is not observed in ail cases ; it présents 
the greatest différences with respect to its intensity, sometimes being very slight, 
and being mentioned by the patient only when he is questioned on the subject ; 
sometimes so intense, that it constitutes the prédominant symptom of the disease. 
Its nature varies as its intensity : it is far from always having that lancinating 
character which is laid down as Connecting itself particularly with cancerous 
affections. This kind of pain has been rarely remarked in the différent cases of 
cancer of the brain published up to this day. 

If we consider this pain with respect to its seat, we shall find that in certain 
cases it is gênerai, and by no means indicates the point of the brain which is the 
seat of the lésion ; whilst in other cases it exists only on one side, and is then of 
more value as a diagnostic sign ; but if in this case it is explicit regarding the seat 
of the affection, can it reveal its nature ? Certainly not ; for it may be produced 
by several other lésions, and, among them, by a softening, as we have seen. Is it 
then by its particular character, or by its intensity, that we shall distinguish the 
pain of cérébral cancer from that which accompanies other affections of the ence- 
phalon ? We never can attain more than mere probability on this subject. 

The pain of cancer of the brain simulâtes in some cases a neuralgia by the 
manner in which it radiâtes, from always the same point, towards other parts of 
the cranium. As a neuralgia, it may develope itself under an intermittent form, 
without, however, there being any regularity in its returns. As certain pains 
called nervous, we have seen it diminish by gTeater or less pressure made on the 
points which it occupies. Bleedings, which have no influence on the organic 
affection of which it is a symptom, may, however, diminish it or even make it dis- 
appear for a time. Amongst the cases that have been published, there are sorae 
in which we see the pain return, or become exasperated at the return of each 
menstrual* period, then cease or diminish, once the blood has commenced to flow. 
In ail thèse cases, however, the organic lésion continues the same ; but around it 
the state of the nervous substance is continually changing. 

* No doubt at each menstrual period the modification experienced by the utérus is felt 
through ail parts of the system. Numerous facts might justify this assertion : here is a strik- 

ing example of it : AVe know a lady in -whom, at the return of the menses, the skin of one 

of her aims, which has the mark of a cautery, reddens and becomes the seat of very severe 
itcbing. 



DISEASES OF THE ENCEPHALON. 



189 



The pain of which the head is the seat in cancer of the brain, may be repeated 
in other parts. Thus in certain cases individuals labouring under this affection 
have experienced in the tTunk and extremities pains more or less acute, which 
simuiated very closely rheumatic or nervous pains. Others have presented an 
extraordinary exaltation of the cutaneous sensibility ; the skin could not be touched 
without a most painful impression being felt, whilst at other times, on the contrary, 
the skin lost ail sensibility. Sometimes, in fine, an insupportable itching tormented 
the patient. Thus from one and the same lésion, the brain, in each individual, 
reflects on the organs the infinité diversity of its impressions, by the diversity of 
the phenomena which it occasions there. 

The functions of the organs of the sensés have been changed in some cases, 
though the nerves appertaining to them were not comprised in the cancerous 
dégénérescence. Nothing can be more remarkable in this respect than a case 
published in a periodical regarding a girl seventeen years of âge, who lost succes- 
sively the use of ail her sensés, and in whom motion was at the same time de- 
stroyed, whilst in the midst of ail this disturbance, the intelligence remained intact. 

In three cases of cancer of the pituitary gland, which have been published, 
there was amaurosis ; but this circumstance depended no doubt on the participa- 
tion of the optic nerves in the disease. 

In one of thèse cases, the first symptom had been a graduai weakening of 
vision, accompanied by acute pains in the forehead. For three years nothing else 
was observed ; there then came on stupor, more and more profound, in which the 
patient died. 

With respect to the life of nutrition, nothing particular is observed. In some 
individuals, obstinate vomiting has been observed, a phenomenon which is found 
in a certain number of cérébral affections, acute or chronic, very différent from 
each other. 

The pale yellow tint of the face is not here more constant than in other cancerous 
diseases. 

Nothing is more variable than the duration of cérébral cancer ; at times some 
months only elapse between the appearance of the first symptoms and death ; 
sometimes thèse symptoms are prolonged for several years before bringing the 
fatal termination. The latter may corne on in two ways : either the signs of an 
acute encephalitis corne on, and the individuals die either of coma, or of convul- 
sions, or else they waste away gradually ; their strength is lost, ail their functions 
become deteriorated ; intervening inflammations attackthe lung, or the primas vise ; 
eschars form on the skin, and death is the resuit of ail thèse combined causes of 
destruction. 

The following cases collected by ourselves, may be added to those which 
science already possesses. 

Case 1. — Pain of head of long standing, limited to one side of the cranium — 
Hemiplegia — Intermitting symptoms of cérébral congestion — Cancer in the right 
hémisphère. 

A man, fifty-eight years of âge, of a strong constitution, felt for the first time, 
fîfteen years since, an acute pain which spread from the right temple over the 
entire right side of the head and face. This pain remained during six weeks. 
The following years, it returned several times without having any thing regular 
either in its returns or in its duration. It appeared, two months ago, with more 
violence than ever : it soon became sufficiently intense to compel the patient to 
give up his occupations. A blister applied to the temples quieted him for some 
time. Having entered the La Charité, 15th November 1821, the patient was in 
the following state : — 

Countenance yellow, dejected ; intellectual and sensorial faculties intact, except 
that there existed from time to time a temporary diplopia ; muscular strength 



190 



CLINIQUE MEDICALE. 



preserved ; violent pains in the right side of the head, extending sometimes to the 
corresponding side of the face, becoming worse at intervais, so as to make the 
patient scream, sometimes lancinating, sometimes resembling a flame of fire passing 
through the head ; right eye habitually weeping ; puise strong and slow ; diges- 
tion and respiration natural. (Anodynes to the right temple, mustard pediluvia, 
blister to nape of neck). 

Though the state of the patient appeared nearly the same during the night, the 
pain became insufferable. The 21st November, the patient having got out of the 
bed, felt his legs bend under him and fell. The next day, 22nd, his eyes were 
closed ; he answered no questions. (Thirty leeches to anus, sinapisms, and 
purgative lavement.) 

The 23rd, stupor ; answers questions ; right upper eyelid paralysed ; rigfnt com- 
missure of the lips drawn up ; no voluntary movement in the extremities of the 
left side ; no déviation of the tongue ; préservation of the sensibility ; pain of 
head much less. (Arnica, senna lavement.) 

From this period the preceding symptoms continued ; besides the patient 
became rapidly debilitated ; his features became altered ; his countenance as- 
sumed a still more yellow tint ; his puise became soft, accelerated. and presented, 
besides, from one day to another, the greatest variations ; the tongue was 
aJternately brown and vermilion colour, dry and moist ; several times the patient 
was found plunged into a profound coma, with a trachéal râle, which seemed to 
announce his approaching dissolution ; the day after this râle no longer existed or 
was much less, and the intelligence was re-established ; the patient no longer 
complained of pain of head ; he was in a state of apathy, or as it were, indiffèrent 
to his situation ; he resembled a person who had just got out of a profound sleep ; 
his eye was closed and void of expression (blisters to the chest and leg, décoction 
of potygala, laxatives) ; the adynamic state went on ; the stupor and râle become 
continuai ; the extremities become cold, and the patient sinks. 

Post mortem. The sub-arachnoid cellular tissue was infiltrated with a moderato 
quantity of sérum. Viewed externally the circumvolutions of the right hémi- 
sphère seemed flattened. When eut in thin slices to the level of the corpus 
callosum, the brain presented nothing remarkable, except that there flowed a con- 
sidérable quantity of sérum from each latéral ventricle. Anterior to the optic 
thalamus of the right side was a sraall softening of the size of a twenty sous 
pièce : there, the cérébral substance, slightly yellowish, was reduced to a diffluent 
pulp, but outside the right optic thalamus, and the corresponding corpus striatum, 
there existed another species of altération. For the extent of four fingers' breadth 
in length, and of two or three in breadth, there appeared a surface of a reddish 
grey, wrinkled, uneven appearance, presenting altogether the aspect of certain fun- 
gous growths of the dura mater. On cutting into this part, the scalpel experienced 
a résistance similar to that which scirrhus growths of the stomach and liver 
oppose to it. Here there was found a tissue as it were areolated, of a bluish 
white, half transparent, very hard, and marked here and there with small cavities 
full of a liquid similar in appearance to apple-jelly (scirrhus in the state of crudity 
or softening.) In other points there was seen a tissue of a dirty white colour of 
considérable consistence, and traversed by reddish lines crossing each other in 
différent directions. In other points, in fine, nothing was found but a sort of 
reddish bouillie. This altération prevailed, in depth, from the level of the optic 
thalamus to near the base of the skull. The cérébral substance, healthy around 
it, was connected to it by continuity of tissue. Parietes of the left ventricle a 
little hypertrophied. 

Remarks. — We see in this case a violent hemicrania appear single and un- 
attended by any other ailment for several years, and thus isolated from every 
other symptom, assume ail the character of a true neuralgia ; it is, however, very 
probable that it depended on the organic lésion of which the brain was the seat. 



DISEASES OF THE ENCEPHALON. 



191 



The altération of motion came on suddenly, as if the cérébral substance had 
become the seat of hemorrhage or softening. It is not in this way that paralysis 
usually commences, which dépends on a cancerous affection of the brain, and 
that is, no doubt, one of the most remarkable circumstances of this case. What 
is not less worthy of attention is, those species of periodical crises, the probable 
resuit of an intermittent cérébral congestion, during which the patient sunk into a 
profound coma, presented the trachéal râle of one in the last agony ; the latter 
disappeared as well as the coma, the intelligence was restored, and immédiate 
death was no longer to be apprehended. This we observed several times ; death 
came at last in conséquence of the continuance of a similar crisis. 

Case 2. — Hemiplegia of long standing preceded by pains occupying the side of the 
cranïum opposite to the paralysis — Intelligence perfect ; suddenly a violent attack 
of epilepsy, followed by profound coma, m which the patient died. 

A man, forty-seven years of âge, was affected with complète hemiplegia of the 
right side when he was seen by us. This man, who still retained ail his intel- 
ligence, told us that for the last three years he habitually felt in the left side of 
the cranium a pain which he attributed to rheumatism ; he had had several attacks 
of this latter affection. The pain which he felt never entirely ceased ; but though 
in gênerai rather dull, it became occasionally much more acute, and then was 
accompanied by copious vomitings of a green substance. He considered this 
periodical exaspération of his headach a megrim. 

For two years he experienced no other uneasiness but this pain of head, which 
did not, however, prevent him from attending to his usual avocations. At the 
end of this time, and after one of thèse megrims, which had been very violent, and 
which was continued beyond the ordinary time, he began to feel in the hand and 
foot of the right side an annoying formication, which went away of its own accord 
after some days. Two months after, he had another attack of megrim as violent 
as the preceding, and after it the same sensé of formication reappeared. But this 
time it no longer ceased, and the right extremities soon became weaker than those 
of the left side, and then they became completely paralysed. The paralysis was 
not complète till about eight months after the fîrst appearance of the formication. 

When we saw the patient he had his pain of head constantly ; the muscles of 
the face were the seat of slight convulsive twitches, resembling a sort of tic, 
which were not perceived by the patient ; the extremities of the right side were 
completely deprived of motion, and the skin covering them was much less sensible 
than that of the extremities of the left side ; the organs of the sensés not affected ; 
puise sixty-eight, regular and full. 

Ten or twelve days passed on without the state of the patient presenting any 
change. At the end of this time the pain of head became suddenly aggravated ; 
his features were very much altered by the pain ; he cried out aloud for some 
relief ; he vomited during the time an enormous quantity of green bile ; the puise 
had become very fréquent, and the muscles of the face became much more 
violently convulsed than usual. In this state we were desirous to try the effect 
of a bleeding ; sixteen ounces of blood were taken without any amendment. A 
littie time after this the patient suddenly lost ail consciousness, convulsive move- 
ments appeared, and ail the phenomena characterising an epileptic attack were 
observed. The convulsions soon ceased, but they were succeeded by a profound 
coma, in which the patient died during the night. 

Post mortem. A cancerous mass, the size of a pullet's egg, possessing the same 
characters as those described in the preceding case, occupied the central part of 
the left hémisphère of the brain ; it had taken possession of the optic thalamus 
and corpus striatum of this side ; the entire encephalic mass was very much 
injected. The organs in the other cavities were sound. 

Remarks. — This tedious disease terminated by a violent attack of epilepsy, and 
commenced as that detailed in the flrst case, by a headach which for a long time 



192 



CLINIQUE MEDICALE. 



did not appear connected with any serious lésion. Between thèse extrême 
periods we observe a paralysis occurs, which is established gradually, and com- 
mences after one of the aggravations of the headach ; the intelligence continued 
more perfect here than in the subject of the first case ; we shall see, on the con- 
trary, the disturbance of this fonction very well marked in the subject of the 
following case. 

Case 3. — Temporary signs of mental aliénation — Intelligence hàbitually very obtuse — 
Contraction of the extremities of the right side — Prostration of strength becoming 
greater, and deaih. 

A woman, forty-eight years old, entered the La Charité with her intellects so 
dull that we could obtain no information from her respecting the previous history 
of her case. The questions put to her she answered very vaguely : she scarcely 
knew where she was. Ail we could learn from those who brought her was. that 
when she had her intelligence, she had had at différent times attacks of mania for 
which she was admitted twice at the Salpétrière. By degrees she fell into a sort 
of idiotcy, and it became necessary to attend her as a mere infant. She had also 
strong contraction of the upper and lower extremities of the right side. Since her 
admission, this woman was very much debilitated ; tongue dry, and an eschar 
already formed on the sacrum. The following days the adynamic state became 
more and more rnarked, severe diarrhœa came on, the respiration became ster- 
torous, and the patient died shortly after. 

Post mortem. The vault of the cranium had been hardly removed, and the 
dura mater eut into when we were struck with the uneven appearance of the cir- 
cumvolutions of the middle lobe of the right hémisphère ; they were very much 
deformed, and very différent from those of the opposite side. We found them 
very hard ; they sounded under the scalpel. This unusual hardness extended in 
depth to a little above the level of the centrum ovale of Vieussens, the optic 
thalami and corpus striatum not being at ail affected. In every part where the 
cérébral substance was thus hardened, it was at the same time changed into a fatty 
(lardacé) tissue which had ail the characters of scirrhus ; in several parts this 
tissue was marked by small cavities, which were filled with a greyish white sub- 
stance, like glue. Three or four cretaceous tubercles, surrounded by a black 
indurated tissue, were found in the summit of the two lungs. The mucous 
membrane of the stomach presented a slate-coloured tint, and a greater consistence 
than natural in ail the pyloric portion ; towards the great cul de sac, ît was red- 
dish and soft. The mucous membrane of the end of the ileum, and that of the 
caecum were very much injected without being softened. 

Remarks. — Here is a case in which the symptoms of cancer of the brain are no 
longer the same, in some respects, as in the first and second case. At first, instead 
of simple paralysis, there was contraction of the limbs ; but what particularly distin- 
guishes this case from the two preceding is, the disturbance which the intelligence 
underwent, namely, those temporary altérations of reason which terminated finally 
in a kind of madness. 

In thèse three cases the nature of the lésion was identical ; but it had not the 
same seat : in the two former the circumvolutions remained intact, in the third 
they were affected ; and, without intending to draw any gênerai conséquence, we 
cannot help remarking that it was only in the case where the circumferenee of the 
brain participated in the cancerous dégénérescence that the intellectual faculties 
were compromised. 

It is not pathological anatomy that can here inform us, why, in the two first 
cases, there was simple paralysis, and contraction in the third case. We cannot 
but remark, also, the entirely différent manner in which death came on in thèse 
three cases. Here we observed no coma, no epileptic or other convulsions ; we 
find merely prostration of strength graduaîly increasing, induced in some degree, 
«o doubr, by the state of the digestive tube. 



DISEASES OP THE ENCEPHALON. 



193 



Case 4. — Cancer of the brain, which was repeated in the kidneys, and in several of 
the bones — Parait/sis of one of the upper extremities — Headach — Remarkable 
state of apathy. 

A man, forty-five years old, complained to us, when entering the La Charité, of 
a pain in the left coxo-femoral articulation ; the parts surrounding it were the seat 
of considérable swelling ; we found also most of the signs of fracture of the neck 
of the fémur ; snortening of the limb ; turning of the point of the foot outwards ; 
inability to rlex the thigh on the pelvis, the leg being extended on the thigh ; the 
left great trochanter more projecting, and nearer the crest of the ileum than that 
of the opposite side : ail motion of the joint impossible. The patient assured us 
he had not had a fall ; that he never had suffered any external violence ; 
the face had a very remarkable pale yellowish hue. Another phenomenon struck 
us, namely, complète paralysis of the entire left upper extremity. The patient 
told us that he had insensibly lost the use of this lirnb ; about six or seven months 
since, he perceived that he could not use it with as much ease as the other : from 
time to time he experienced acute pains in it. He told us thaï, for the last five 
or six months, he was annoyed by an almost constant, headach, principally seated 
in the right side of the cranium : he complained of no pain in any other part of 
the body. The digestive and respiratory functions were intact ; puise was some< 
what aceelerated, 

This man, who seemed to labour under an affection purely surgical, complained 
of nothing ; he scarcely answered the questions put to him ; we were struck every 
morning with the state of apafchy in which he seemed to be sunk. In conséquence 
of lying constantly on his back, his sacrum became excoriated ; this excoriation 
was ultimately converted into a large uîcer, which went on increasing in depth and 
breadth. From this time he became weaker, his tongue dry and black, his teeth 
and lips were covered with dark coloured crusts. For the last twenty-four hours 
of his life, his respiration became remarkably slow ; each inspiration seemed to be 
his last, so long was the interval between them, and he died. 

Post mortem. We found the left optic thalamus, and nervous substance sur- 
rounding it, changed into a lard-like tissue, possessing ail the characters of 
cancerous matter. No other morbid change was found in the encephalon. A 
frothy, colourless sérum flowed in great abundance from the two lungs. The 
mucous membrane of the stomach had for the greatest part of its extent a slate- 
coloured tint. The left kidney was occupied, for at least the three fourths of its 
extent, with a dull white tissue traversed by numerous reddish lines : being hard 
in certain parts, this tissue resembled in other parts softened cérébral substance : the 
dégénérescence of the parenchyma of the kidney into encephaloid tissue could not 
be mistaken. The same altération existed in the right kidney, but to a less extent. 

The head of the left fémur was entirely separated from the body of this bone ; 
in the place of its neck, the bony substance of which was entirely destroyed, there 
was found a half-liquid substance, of a brick-red colour, similar to the reddish 
détritus resulting from the softening of the encephaloid tissue. A simiîar sub- 
stance filled the rnterior of the head of the fémur. This head merely consisted of 
a hollow sphère with very thin parietes ; it is probable that, in a little time more 
it would have entirely disappeared. The upper extremity of the lower portion 
was marked with numerous asperities. 

Thethird, fifth, sixth, and seventh ribs on both sides, presented several solutions 
of continuity, and in the place which should have been occupied by the destroyed 
bony tissue, there was found a reddish substance similar to that interposed between 
the head of the bone and its body. The sixth rib on the right side presented 
three similar solutions of continuity. On examining the bones of the cranium, we 
found that the right pariétal bone presented at its anterior and middle part, an 
irregularly rounded perforation, large enough to admit the end of the thumb : this 

o 



194 



CLINIQUE MÉDICALE. 



was filled by the same reddish matter already described. This substance was 
spread over the dura mater to an estent at least three or four times greater than 
that of the perforation îtself : beneath it the dura mater was sound. The first 
pièce of the sternum was in a great measure changed into this same reddish 
substance. 

Remarks. — A pain of head, of several months' standing, but which was no longer 
exasperated at intervais as in the preceding cases ; a paralysis gradually established, 
the existence of which could be ascertained only in the upper extremity opposite 
to the injured hémisphère ; finally, towards the latter period, a remarkable kind of 
apathy, such were the only symptoms indicating in this individual cancer of the 
brain : but this cancer was only one of the éléments of the disease under which he 
laboured. The reader's attention is directed to the répétition of this same cancer, 
both in the bony System and in the urinary organs. 

Case 5. — Cancer of the brain, liver, spleen, stomach, utérus, ovaries, and of a great 
number of lymphatic ganglions. 

A woman, about forty years of âge, presented nothing else, during her stay at 
the La Pitié, but the ordinary signs of cancer of the utérus : with respect to the 
nervous centres she evinced no appréciable functional disturbance : she died of 
pleuritis of the right side which terminated in a sero-purulent effusion. 

Post mortem. A small cancerous mass, the size of a pea, in the left corpus 
striatum ; another, the size of a nut, at the junction of the middle and posterior 
lobes of the right hémisphère : effusion into the right pleura ; numerous cancerous 
masses in the liver and spleen ; scirrhous thickening of the tunics of the stomach 
around the pylorus ; cancerous dégénérescence of the body and neck of the utérus, 
and also of the ovaries, 

Remaries.— In this case, as in the preceding, the cancer found in the brain was 
but an élément of a more gênerai disease. The absence of cérébral symptoms 
may be accounted for by the small size of the cancerous masses found in the brain. 



THIRD BOOK. 

D1SEASES OF THE CEREBELLUM. 

Thèse diseases are much rarer than those of the cérébral hémisphères. We 
collected but sixteen in a period of fifteen years of attendance in the hospitals. 
We shall record them and bring in juxta-position with them those already pub- 
lished by différent writers ; we shall endeavour to draw from the comparative 
study of thèse différent cases some conséquences relative to the functional dis- 
turbances occasioned by lésions of the cerebellum. 



SECTION I. 

OBSERVATIONS ON HEMORRH AGE OF THE CEREBELLUM. 

In the six following cases, hemorrhage of the cerebellum existed single three 
times, and three times it coincided with an effusion of blood into one of the 
cérébral hémisphères. 



DISEASES OF THE ENCEPHALON. 



195 



Cases. — Effusion of blood into the right hémisphère of the cerebellum — Hemiplegia on 
the left side, acccmpanied with lo;s of consciousness — Death fifty hours after the 
appearance of the first apoplectic symptoms. 

A female, twenty-one years of âge, was treated at the La Charité for a chronic 
gastritis : she evinced symptoms of it for the last two years. One evening at six 
o'clock, a little time after having eaten, and before going to bed, she fell, suddenly 
deprived of consciousness and motion ; after about an hour she recovered the use 
of her sensés, but could not move the extremities of the left side, On seeing her 
the next morning her state was as follows : — Face injected equalîy on both sides ; 
contraction of the pupils ; vision preserved ; air of stupor ; she answers questions 
with correctness ; no embarrassment of speech. The two extremities of the left 
side completely deprived of voluntary motion ; they presented no trace of con- 
traction ; sensibility of the skin covering them impaired. Puise seventy-five and 
full ; heat of skin natural ; respiration hurried (thirty to thirty-four every minute), 
This girl seemed to us to have been struck with cérébral hemorrhage ; she was 
bled to sixteen ounces. 

At the following visk her state was much worse ; she was sunk in a profound 
coma ; does not any longer answer questions ; skin insensible to the action of 
excitants, on the right as well as on the left. The extremities of the right side, 
when raised, sustain themselves for some seconds in the air, and fall back gradually; 
not so the extremities of the left side, which fall as inert masses ; respiration very 
stertorous. ïn the course of the day the symptoms of carus becaine more and 
more marked, and the patient died at eight o'clock at night. 

Post mortem. Cranium. — Sub-araehnoid cellular tissue of the convexity of the 
cérébral hémisphères very much injected. The latter présent no appréciable 
altération, except considérable sandiness of their tissue. In the central part of 
the right hémisphère of the cerebellum, was found an effusion of blood which 
formed in the nervous substance a cavîty large enough to hold a pullet's egg. 
Around this cavity the tissue of the cerebellum was red and softened for the space 
of three or four lines. 

Thorax. — Sero-sauguinolent infarction of the two lungs, and particularly of the 
left. Heart and its appendages natural. 

Abdomen. — Scirrhous induration of the sub-mucous cellular tissue of the sto- 
mach in ail its pyloric portion ; beneath this tissue considérable hypertrophy of 
the muscular tunic, w r hich was divided into large fasciculi by whitish lines belonging 
to the thickened cellular tissue. In some parts, no trace of the fleshy tunic, and 
there is notbing found but a homogeneous scirrhous mass. The mucous mem- 
brane of a slate-colour hue, and thickened. 

Case 2. — Hemorrhage into the right hémisphère of the cerebellum — Sudden loss of 
consciousness — Hemiplegia on the left side — Death very rapid. 

A man, thirty-eight years of âge, entered the La Charité in the course of the 
month of March, 1824. presenting ail the symptoms of an organic affection of the 
heart. A well-marked bruit de soufflet was heard at each contraction of this 
organ. After complaining for some day s of dizziness and headach, the précise 
seat of which he was unable to point out, he was struck with a violent fit of apo- 
plexy : coma, sudden and profound ; gênerai insensibility to external stimulants. 
As yet, no real paralysis except on the left side ; if the limbs of the right side be 
raised, they fall again but slowly ; if those of the left. side be raised, they fall sud- 
denly, as inert masses. On pinching the skin severely, the extremities of the right 
side are seen to move, at the same time that the muscles of the face contract, and 
a siight moan is heard ; on the contrary, the extremities of the left side are 
imrnoveabîe. 

o 2 



196 



CLINIQUE MÉDICALE. 



Such was the state in which we saw the patient at our visit, about fifteen hours 
after the attack ; the respiration vras very stertorous ; puise not fréquent, but 
compressible ; it presented m an y irregularities ; this state appeared to us to be 
connected with the affection of the heart. He died a few hours after the visit. 

Post mortem. Craniurn. — No appréciable lésion in the cerebr-al hémisphères, 
nor in the membranes covering thern. Right hémisphère of the cerebellurn 
transformed into a sort of pouch fille d with black blood simîlar to currant- 
jelly- . 

Thorax. — The heart presented an unusual size, depending on the anormal state 
of the auricles ; they were both considerably dilated, and their parietes very much 
hypertrophied ; the right auriculo-ventricular valve was hard and thickened, par- 
ticularly at its free edge. In the left, the mitrai valve was still more thickened, 
cartilagînous in some points, and bony in others. It constituted a ring or immove- 
able diaphragm, through the opening of which the index finger could scarcely be 
introduced. The aortic valves were ossified at their base. The ventricles pre- 
served their normal state. 

Case 3. — Effusion of blood into the left hémisphère of the cerebellurn — Hemiplegia 
on the right side — Intelligence dull — Subsequently afall — State of coma — Death. 

A woman, seventy-five years of âge, entered the La Charité in the following 
state : — Countenance pale, expressive of stupor ; state of the intelligence very 
duH ; complète paralysis of the extremities of the right side ; tongue dry and 
brown ; diarrhœa ; puise fréquent ; skin hot. We obtained no information on the 
preceding history. 

For the five or six following days no change took place. At the end of this 
time, the patient, wishing one morning to leave her bed, tell, and was deprived of 
consciousness ; from that time there was coma ; gênerai resolution of the limbs ; 
death two days after the fall. 

Post mortem. Craniurn. — Pia mater covering the convexity of the cérébral 
hémisphères was infiltrated with sérum ; there was a great quantity also in the 
ventricles. 

Clots of blood filled the occipital fossa of the left side ; this blood escaped 
through a rent which was perceived in a point of the esternal posterior part of the 
circumference of the left hémisphère of the cerebellurn. By pressing on this 
hémisphère, more was made to flow from it. The rent just alluded to led us by a 
canal which was fistulous, short, and filled with blood, in the midst of a cavity 
formed in the substance of the lobe of the cerebellurn itself, and large enough to 
admit at least a large nut. This cavity contained black blood, half liquid, half 
coagulated. Its parietes were lined by a reddish membrane of about a line in 
thickness, easily detached from the subjacent tissue. Around this cavity, the 
substance itself of the cerebellurn was not softened, and had not undergone any 
alteration. 

Thorax. — Considérable infarction of the lungs. Hypertrophy of the parietes of 
the left ventricle of the heart ; some points of ossification towards the adhèrent 
edge of the sigmoid valves of the aorta. 

Abdomen. — Reddish softening of the mucous membrane of the stomach towards 
its great cul de sac. The cavity of the utérus filled with blood, and the tissue of 
the body of this organ intensely red. 

Case 4. — Double effusion of blood, one into the left hémisphère of the brain, and the 
other into the left hémisphère of the cerebellurn — Hemiplegia on the right side. 

A man, sixty-three years old, was struck, on leaving the table, with an attack of 
apoplexy. He was brought the same evening to the La Pitié. VThen we saw 
him the following morning, he had partly recovered consciousness ; he understood 



DISEASES OF THE ENCEPHALON. 



197 



the questions put to him, but answered stammeringly, and in a way almost unin- 
telligible. The left commissure of the lips drawn up ; we could not prevail on 
him to put his tongue out. Right eye lid more depressed than the left ; sensibility 
of the two sides of the face apparently equal ; sees equally well with both eyes ; 
arm and leg of the left side capable of motion of every kind, but the extremities of 
the right side remained immoveable ; ail possible positions were given them, with- 
out the shghtest résistance being made ; the skin côvering them felt less acutely 
than on the other side. Respiration high and fréquent (bleeding to sixteen ounces, 
purgative mixture, sinapisms to the lower extremities)^ 

The folio wing morning we found the patient in the same state. Blood drawn 
not buffed j purgative acted well (thirty leeches to the neck, blister to each thigh). 

During the day new symptoms appeared. The patient, who, till then, had 
remained in a state of apathy, began to be rery much disturbed, and to rave ; he 
cried and spoke incessantly. Towards evening he fell into a state of coma and 
died in the night. 

Post mortem. The pia mater, covering the convexity of the hémisphères, was 
very much injected ; this injection more marked in the left than in the right. The 
grey substance of the circumvolutions showed a well-marked rose-coloured tint. 
About one inch below the circumvolutions of the left hémisphère of the brain, 
there appeared an enormous cavity filled with black blood half coagulated ; this 
cavity terminated on the level of the centrum ovale of Yieussens ; it occupied ail 
the middle lobe, and a little of the exterior and posterior lobes. Around it the 
cérébral substance was as it were ecchymosed for a space of four or five lines ; it 
lost its consistence only for the space of one or two lines from the cavity ; no 
membrane lined the parietes of the latter. No other lésion existed in the 
cérébral hémisphères ; much sérum accumulated in the ventricles. 

A second effusion of blood existed in the centre of the left hémisphère of the 
cerebellum. The accidentai cavity produced by it might admit a nut ; around it 
the tissue of the cerebellum was considerably injected without being softened. 
However, a stream of water poured on the thin parietes of this cavity, discovered 
there a great number of red or whitish filaments, resulting from the tearing 
experienced by the nervous substance. 

Case 5. — Two attacks of apoplexy, ihree months intervenmg between each — Hemi- 
plegia of the right side after the first — Apopleetic cyst in the left hémisphère of 
the cerebellum — Récent hemorrhage in the right hémisphère of the brain. 

A woman, aged sixty-seven years, had had an attack of apoplexy two months 
and a half before entering the La Charité. After this attack, of which the 
symptoms could not be narrated to us with sufficient précision, she remained 
paralytic on the right side. When we first saw her, motion was entirely abolished 
in the two extremities of this side, and their sensibility impaired ; intelligence and 
speech perfect ; the sensés not affected. After remaining fifteen days in the 
same state, she was struck with a second attack of apoplexy, of which she died in 
the course of some hours. 

Post mortem. An immense effusion of blood into the right hémisphère of the 
brain ; it took possession of the optic thalamus, the corpus striatum, and a con- 
sidérable portion of the nervous mass above and external to thèse parts ; the 
effused blood has the colour and consistence of currant jelly ; the effusion 
evidently quite récent. 

In the left hémisphère of the cerebellum, on the contrary, was another 
lésion of an older formation, indicating that an old hemorrhage had taken place 
in this part. The cavity here is large enough to admit a mit, containing a clot of 
blood of a brown red colour, and solid, around which was formed a membrane 
entirely resembling a serous one ; around this cavity the substance of the cere- 
bellum is a little soft and yellowîsh. 



198 



CLINIQUE MÉDICALE. 



Case 6. — Double hemorrhage, one qf whick is in the right hémisphère qf the cere- 
bellum, and the other in the left hémisphère qf the cerebrum — Hemiplegia on the 
right side — Loss of consciousness. 

A hôtel keeper, forty-nine years of âge, fell in the street deprived of conscious- 
ness, after haying indulged in excessive drinking. He was instantly conveyed to 
the Maison de Santé, and was bled to a considérable amount. For the first hour 
after the bleeding there seemed some return of consciousness, which, however, 
was soon again succeeded by profound coma. 

The following morning when we saw him, he was in a state of stupor from 
which nothing could arouse him ; the strongest pinching seemed to have no effect 
on him ; vision gone ; the loudest noises near his ear produced no movement in 
him ; the four extremities were immoveable, in a state of relaxation, and seemed 
as incapable of motion on one side as on the other. Still we were assured that 
the evening before, after being bled, he moved the extremities of the left side 
with ease, whilst those of the right side seemed paralysed ; face red, injectée! ; 
puise hard and fréquent ; skin hot. We had him bled again to twenty ounces, 
and ordered twenty leeches to be applied after the bleeding to each mastoid 
process, which were let bleed the entire day, whilst a bladder full of ice was 
applied to the head, and sinapisms to the lower extremities. 

Towards the end of the day the patient emerged from his state of coma ; he 
seemed to recover a little intelligence. When we saw him again, his eyes were 
open, and he seemed to pay some attention to the questions addressed to him ; 
however, he seemed not to understand them, and did not answer. The left com- 
missure of the lips was dragged, and the tongue when put out of the mouth 
inclined to the right ; he moved the left extremities with ease ; those of the right 
side were completely deprived of motion, and the sensibility of the skin covering 
them was very much impaired ; the puise was become slow ; the respiration 
hurried, but not stertorous ; neither was it so the preceding day. (A blister was 
applied to the nape of the neck, ice to the head still continued.) 

In the course of the day, the patient relapsed into coma, and he died in the 
night. Up to the last moment he had the power of moving the extremities 
of the left side. 

Post mortem. A large effusion of blood occupied at least the third of the 
left cérébral hémisphère ; it commenced a little beneath the circumvolutions 
which were intact, and affected the optic thalamus and corpus striatum ; it 
made its way into the left latéral ventricle. The septum lucidum was not 
torn. 

A second effusion of blood was discovered in the right hémisphère of the 
cerebellum, and occupied the half of this hémisphère ; it was nearer to the 
upper than the lower surface. 

ïtemarhs. — In the six preceding cases, the hemorrhage of the cerebellum 
differs in nothing, with respect to the symptoms, from hemorrhage of the 
cerebrum. 

In ail thèse there is paralysis, and it occurs on the side opposite to that on which 
the effusion of blood takes place, except in the last case, which forms an exception. 
From thèse facts, we feel warranted in concluding that the influence of the cere- 
bellum crosses, as well as that of the brain, and yet the fibres of the spinal 
marrow which enter into the corpora restiformia, do not corne from the oppo- 
site side of this cord. The argument which had been considered available to 
explain the crossing influence of the brain, is no longer so here. 

The intelligence présents in its disturbances the same varieties as in the cases 
of hemorrhage of the brain, so that the disturbance of this faculty seems to dépend 
less on the seat of the lésion than on its intensity. 



DISEASES OF THE ENCEPHALON. 



199 



The sensibility présents no particular disturbance ; it is merely iinpaired or 
destroyed, as in cases of cérébral hemorrhage. 

With respect to the génital apparatus, it présents nothing remarkable, except in 
the woman who forms the subject of the third case. In her there was considér- 
able congestion of the utérus. We satisfied ourselves that in the maies there was 
no érection of the pénis, because they were entirely uncovered, and examined 
naked, in order to ascertain the state of the lower extremities. 

With respect to the commencement of the disease, it is still the same as in the 
individuals whose brain, properly so called, is the seat of hemorrhage. Thus we 
see our patients fall suddenly deprived of consciousness, and become at the same 
time struck with paralysis. 

Let us now add to thèse six cases observed by ourselves the other cases of 
hemorrhage of the cerebellum published up to the présent time. 

We have found in médical authors twenty-two cases of hemorrhage of the 
cerebellum, nine of which were in the middle lobe, and thirteen in the latéral 
lobes. 

Of the nine cases relating to hemorrhage of the middle lobe, six have been 
published by M. Serres *. In thèse six cases, ail the signs of violent apo- 
plexy were observed ; nothing particular is mentioned regarding the disturbances 
of motion. 

A seventh case of hemorrhage of the middle lobe has been mentioned by 
Dancef, in his paper on acute hydrocephalus. The subject of this case was 
struck with apoplexy ; no account is given regarding the movements of the 
limbs. 

An eighth case, relative to this hemorrhage, was published by M. Bayle. The 
patient suddenly lost consciousness, but he was not paralysed ; at least, M. Bayle 
assures us, that he drew back his limbs instantly when fhey were touched. This 
individual died comatose on the fîfth day of his attack, after having exhibited, on 
the third day, convulsive movements in the lower extremities, and some rigidity 
towards the nape of the neck. 

We read in the Clinique des Hôpitaux (tom. i. No. 70), a case of M. Guiot, in 
which there is not found, as in eight others, any other lésion than an effusion of 
blood into the middle lobe of the cerebellum. The subject of the case had an 
attack of apoplexy. Before he was struck, he walked unsteadily, and, after the 
attack, he remained hémiplégie on the left side. 

Thus, then, in thèse nine cases of hemorrhage of the middle lobe of the cere- 
bellum the paralysis is absent once ; it is limited to one side another time ; the seven 
other times, the limbs seem to be in a gênerai state of resolution, as happens in 
large cérébral hemorrhages. 

In thèse nine cases, intelligence and sensibility présent the same modifications 
as they would have presented, if the hemorrhage were seated in one of the céré- 
bral hemorrhages. 

The génital apparatus is, on the contrary, modified very particularly in seven of 
thèse nine cases, whether maie or female. 

First, in the maie, M. Serres saw five times (the subject of his sixth case was a 
female) the phenomenon of érection coincide with hemorrhage of the middle lobe. 
This same phenomenon was noted in the case published by M. Guiot. Still 
further, in this case, the patient, before the attack, was attacked by continuai 
érections and fréquent pollution. 

The female who formed the subject of M. Serres' case was seventy years of âge. 
Her menses reappeared at the time she was struck with apoplexy ; after death, 
her utérus was found filled with blood, and the tubes and ovaries considerably 
iniected. 

* Anatomie du Cerveau, tom. ii. f Archives de Médecine, Jan. 1 830, p. 42. 



200 



CLINIQUE MEDICALE. 



We shall now pass on to the analysis of the thirteen cases, wheie the 
hemorrhage took place in one of the hémisphères, or of the latéral lobes of 
the cerebellum. 

Thèse cases, as also the sex already cited, may be divided into two séries : in 
the first, the hemorrhage of the cerebellum exists withou-t cérébral hemorrhage ; in 
the second, thèse two kinds of hemorrhages co-exist. 

The fir.st of thèse séries comprises seven cases : in three of them only is there 
paralysis, and in ail there it took place on the side opposite to the seat of the 
effusion into the cerebellum. Of thèse three cases, two belong to M. Serres. 
The right hémisphère of the cerebellum was the seat of the hemorrhage, and there 
was hemiplegia of the left side *. 

The third case was published by Dr. Cazes in his Thesis f. The subject of his 
case was a female, seventy-four years of âge, who, after having had for some time 
a great tendency to stupor, lost consciousness quite suddenly, and fell into a pro- 
found carus. When the extremities were pinched severely, those of the left side 
w r ere seen to perform considérable movements ; the right lower extremity con- 
tinued entirely motionless ; the upper extremity of the same side moved, but in a 
manner almost imperceptible. This woman died eight hours after having been 
struck. On examining the body, M. Cazes found the left lobe of the cerebellum 
changed into an immense cavity filled with coagulated blood. 

In the four other cases of hemorrhage of the cerebellum, without co-existence of 
cérébral hemorrhage, there is no mention of hemiplegia. Thus, one of thèse four 
cases, which belongs to MorgagniJ, refers to aman who was found dead, with the 
upper extremities strongly contracted ; there was an effusion of blood into each of 
the latéral lobes of the cerebellum. 

Another of thèse cases was attended by Dr. Sedillot §, in a child seven years 
old, who, after being exposed to a burning sun, was suddenly seized with acute 
pains towards the occipital région : he died a quarter of an hour after the appear- 
ance of the pains. An effusion of blood was, in this case, in the centre of the 
right lobe of the cerebellum. 

A third case, reported by Dr. Cafford ||, contains so few détails, that it can be 
of no use in solving the question now before us. It is merely said, in this case, 
that in an individual who died of apoplexy, blood ivas found effused on the surface of 
the cerebellum and into its grey substance. 

With respect to the fourth case, published by Dr. Michelet in his Thesis f , it is 
deserving of ail our attention. 

This was the case of a girl eighteen years of âge, who, two years before her 
death, had had an attack of apoplexy, the resuit of which was amaurosis without 
any other paralysis, and habituai headach. An apoplectic cavity of an old stand- 
ing was found in the right lobe of the cerebellum. 

Let us now pass to the cases in which there was, at one and the same time, 
hemorrhage into the cerebellum and the cerebrum. Eight cases of this kind have 
been published. 

In one of thèse cases only the effusion of blood took place into the hémisphères 
of the cerebellum and cerebrum of the same side ; it was on the left, and there was 
observed a hemiplegia on the right, the left extremities retained ail the freedom of 
their movements **. 

* Anatomie Comparée du Cerveau, tom. ii. p. 215. 

f Essai sur la Paralyse, par Félix Cazes, 1824, No. 3. 

î De Sedibus et Causis Morborum, Epist. ii. § 22. 

§ Bibliothèque Médicale, tom. xlii. 

|| Archives Générales de Médecine, tom. xxii. 

î\ Essai sur les Rougeurs de la Substance Cérébrale, Thesis de la Faculté, 1827, No. 09. 
** Chambeyron, Dissertation Inaugurale, 1823. 



DISEASES OP THE ENCEPHALON. 



201 



In the seven other cases it was in the opposite hémisphères of the cerebrum 
and cerebellum that the hemorrhages took pîace. 

Thus, there was observed, in the wards of M. Piorry, the case of an individual, 
who had at first ah attack of apoplexy, with hemiplegia on the right side; a year 
after he had a second, but this time it was the extremities of the left side which 
were paralysed. To account for thèse two successive paralyses, M. Piorry found 
two lésions, the one an old one, in the left lobe of the cerebellum ; it was an old 
apoplectic cyst ; the other récent, in the right lobe of the cerebrum : it was a 
softening *. 

In this case the crossing influence of the cerebellum on motion is quite évident, 
and the successive manner in which the hemorrhage took place in the cerebellum, 
and cerebrum. allows us accurately to appreciate the influence of each of thèse 
parts. 

In the other cases, of which we are now to speak, an extraordinary fact présents 
itself ; it is the existence only of paralysis on the side of the body opposite to the 
cérébral hémisphère which was the seat of hemorrhage, whilst the extremities 
opposite to the diseased lobe of the cerebellum remained intact. 

Two of thèse cases were published by Dr. Droullain f. In one of them there 
were two old apoplectic cysts, the one in the left lobe of the cerebellum, the other 
in the external and middle part of the right hémisphère of the cerebrum ; there 
had existed a hemiplegia on the left side. In the other case, there was found, in 
the midst of the left lobe of the cerebellum, a sanguineous effusion the size of a 
nut, and at the same time there was discovered in the right hémisphère of the 
cerebrum, between the optic thalamus and the corpus striatum, the traces of an old 
hemorrhage ; the patient had recently had hemiplegia on the left side. After a 
a fall he exhibited symptoms referrible rather to an acute meningitis than any other 
affection ; alternations of delirium and somnolence ; temporary contraction of the 
extremities of the two sides : convulsive movements of ail the body ; rétroversion 
of the occiput. 

The différent facts which we have now recorded, lead us to the same results as 
those derived from our own expérience. 

From both we may draw the following corollaries : — 

lst. When the effusion which has taken place into one of the hémisphères of 
the cerebellum is sufficiently extensive, without being too much so, it produces 
paralysis of one of the sides of the body. 

2nd. The side of the body paralysed is that which is opposite to the hémisphère 
of the cerebellum, where the hemorrhage has taken place. This fact has been 
ascertained both in the cases of simple hemorrhage of the cerebellum, as also in 
those where there was at the same time hemorrhage of the cerebrum and cere- 
bellum of the same side, or, in other cases, where the hemorrhage of the cerebellum 
had preceded that of the cerebrum, both taking place in the opposite hémisphères. 
M. Piorry's case exemplifies it. 

3rd. Hemorrhage of the cerebellum does not produce hemiplegia, at least, that 
we could discover, in the cases where there was a very severe attack ; then there 
is observed a gênerai resolution of the four extremities, as takes place also in the 
cases of abundant cérébral hemorrhage. 

4th. When the hemorrhage of the cerebellum occurs simultaneously with that 
of the cerebrum, or a little time after it, but so that the blood is effused on the 
right into the cerebellum, and on the left into the cerebrum, or vice versa, there 
is paralysis only on the side of the body opposite to the hémisphère of the brain 
where the hemorrhage has taken place, that is, on the same side as the hemorrhage 
of the cerebellum. How then does it corne to pass that, whereas the movements 

* Lancette Française, No. du 17th Octobre, année, 182.9. 
/ Droullain. Dissertation Inaugurale. 



202 



CLINIQUE MÉDICALE. 



of the extremities of the right side are abolished in conséquence of an effusion of 
blood into the left hémisphère of the brain, the effusion which takes place simul- 
taneously into the right hémisphère of the cerebellum, has no longer the power of 
paralysing the extremities of the left side ? It had this, however, in the cases 
where the brain remained intact : is not that a fact worthy of attention ? 

5th. It is not satisfactorily proved that the contractions of the limbs, convul- 
sions, rétroversion of the head, which have been observed in a case where there 
was simultaneous hemorrhage into the brain and cerebellum, dépend on lésion of 
the latter. Have not similar phenomena been observed, in fact, in cases of simple 
hemorrhage of the brain ? 

6th. Sensibility, placed by some authors in the cerebellum, has not seemed to 
us to suffer spécial or particular lésion in the cases of hemorrhage of this organ. 

7th. The intelligence présents the same modifications as when the effusion of 
blood has taken place into the brain properly so called. 

8th. In none of the cases analysed by us, ail regarding hemorrhage of one of 
the latéral lobes of the cerebellum, no particular phenomenon presented itself with 
respect to the génital organs. 

9th. The functions ofthe life of nutrition exhibited no modification différent 
from those presented by them in individuals who have had hemorrhage of the 
cerebrum. 



SECTION II. 

OBSERVATIONS ON SOFTENING OF THE CEREBELLUM. 

Softening of the cerebellum has been observed much less frequently than that 
of the cerebrum ; up to the présent time there have been but thirteen cases pub- 
lished, to our knowledge ; eight of thèse refer to softening of one of the h teral 
lobes, four to softening of the two lobes together, and one only to softening of the 
middle lobe. Among thèse thirteen cases there are but nine in which the cere- 
bellum alone is affected ; in the four other cases there is at the same time an 
affection of the cerebrum twice, of the pons Varolii once, and of the spinal marrow 
once. We have ourselves met but four cases of softening of the cerebellum ; we 
shall now record them. 

Case 1. — Pain of head in the occipital région of three months date — Hemiplegia of 
the left side established gradually — Latterly convidsive movements of the paralysed 
limbs — Blindness — Considérable softening of the right lobe ofthe cerebellum. 
A seamstress, thirty-one years old, had always enjoyed good health. About 
six weeks before entering the La Charité, she experienced a fright whilst menstru- 
ating : the menses were suppressed, and immediately after their disappearance, 
she was seized with dizziness, and an acute pain in the back part of the head 
towards the right side. The dizziness disappeared after bleeding, but the pain of 
head remained ; it was unconnected with any other symptom for eight days ; 
subsequently the patient began to expérience an annoying sensé of formication at 
the ends of the fingers of the left hand ; she could use this hand but awkwardly, and 
was astonished at seeing what she handled with it fall continually ; soon she 
became unable to work with it ; the entire arm seemed very heavy. After some 
time the lower extremity of the left side became weaker, and in about a month, 
the patient had complète hemiplegia of the left side. But at the same time that 
the patient thus lost the power of motion of one of the sides of the body, her 
sight, till then very good, became very weak, and five weeks after the appearance 
of the first symptoms, she became completely blind. 



DISEASES OF THE ENCEPHALON. 



203 



This was the state in which we first saw her — deprived of sight, and of the 
power of moving the limbs of the left side ; then the pain of head became less 
acute ; the patient, however, still felt it, and referred it to the lower part of the 
occipital région of the right side ; the paralysed limbs were flaccid, and allowed 
theinselves to be moved in ail directions, the skin covering them still retained its 
sensibilité ; no trace of paralysis on the face ; the pupils, moderately dilated, still 
contracted on the sudden approach of light ; the appearance of the eyes natural ; 
there was, however, complète blindness ; she could scarcely distinguish day from 
night ; intelligence perfect ; the puise natural ; the menses had not reappeared 
since they were suppressed by the fright. Leeches were first applied to the nape 
of the neck, then to the génital organs ; aloetic pills were frequently given, and 
subsequently the back of the head was covered with a blister. 

No change appeared for the three first weeks of her stay in the hospital ; then, 
without any known cause, the pain of head suddenly became more violent, and 
extended to the entire cranium ; the extremities of the left side, which till then 
had remained entirely immoveable, were several times agitated with convulsive 
movements, which were slight in the lower extremity, but very violent and almost 
continuai in the upper limb ; acute pains accompanied thèse convulsions ; the 
intelligence soon became disturbed ; complète delirium set in ; for twenty-four 
hours the patient spoke, and became agitated incessantly ; she then fell into a 
profound coma, in which she died. 

Post mortem. The pia mater extended over the convexity of the cérébral 
hémisphères was very much injected, as was also that covering the hémisphères 
of the cerebellum. The substance of the brain, properly so called, was marked 
with a considérable number of red points, and presented no other lésion ; latéral 
ventricles distended with a great quantity of limpid sérum ; the fornix and septum 
lucidum natural. Externally the cerebellum appeared healthy ; but we had 
scarcely removed some layers of the substance of its right hémisphère, proceeding 
from above downwards, when we found an immense cavity, where this substance, 
deprived of its normal consistence, was changed into a greyish bouillie ; this 
softening occupied at least two-thirds of the right hémisphère of the cerebellum ; 
it partly attacked the prolongations which go from the cerebellum, either to the 
spinal marrow, or to the tubercula quadrigemina, or to the annular protubérance ; 
it did not extend as far as the lower surface ; in no part of its extent was there 
either injection or infiltration. 

Remarks. — This softening, seated in one of the hémisphères of the cerebelluns, 
and occupylng a considérable portion of it, presented in its symptoms and progress 
the greatest resemblance to softenings of the brain. Here, again, as in the cases 
of hemorrhage of the cerebellum cited above, the paralysis existed on the side 
opposite to that on which the softening existed. There was neither in motion 
nor sensation any spécial disturbance connected with the fonctions assigned to 
the cerebellum by some physiologists. The intelligence, to be sure, retained ail 
its integrity : but was it not also found to be intact in more than one case of 
softening of the brain ? The seat of the pain alone could incline us to suspect 
that of the disease. With respect to blindness, it seems at first that it has nothing 
to do with diseases of the cerebellum, and yet this case is not the only one in 
which différent affections of the cerebellum have been accompanied by a loss of 
vision. May this fact be explained by the anatomical relations established 
betv/een the cerebellum and the tubercula quadrigemina by means of the pro- 
longations known by the name of processus a cerebello ad testes ? The symptoms 
which su-pervened during the latter period should not, in our opinion, be con- 
nected with softening of the cerebellum : they depended on a complication, and 
we think that we may refer them to the bright red injection presented by the 
méninges, as well as to the great quantity of sérum contained in the ventricles. 
We know of but few cases in which a softening of the nervous centres suc- 



•204 



CLINIQUE MÉDICALE. 



ceeded in so marked a manner to a moral impression ; ihe latter had at the same 
time the effect of suppressing the menses, and it is a remarkable coincidenee that 
in this particular case where there was disturbance in the performance of a fonc- 
tion assigned to the génital organs, the same cause which produced this disturbance 
exercised its influence also on the cerebellum. 

Case 2. — Pain ofhead in the occipital région — Hemiplegia qfthe right side ivith con- 
traction — Préservation of the intelligence — Attack of apoplexy of which the patient 
died — Softening of the central part of the left lobe of the cerebellum — Hemorrhage 
in the cérébral hémisphère of the left side, 

A labourer, fifty-three years of âge, told us when entering the La Pitié, that 
for the last two months he felt a pain towards the posterior and inferior 
part of the cranium ; it existed both on the right and left sides : he lost by degrees 
the power of moving the extremities of the right side, and récent ly the paralysis 
of thèse extremities was complicated with considérable contraction. The sensi- 
bility was retained in the paralysed limbs ; motions of the face not changed ; 
intelligence perfect. 

This patient presented no change in his state ; only he complained from time 
to time of feeling dizziness ; he was bled for this, and also took some gentle lax- 
atives, and had révulsives applied to the lower extremities. One morning, he told 
us that from the preceding day, his dizziness of head was much more severe than 
usual ; the face was very much injected ; he no longer savv ail objects, but through 
a sort of cloud, and his speech became stammering ; he added, that his habituai 
pain in the back part oftrîe head extended to the entire cranium. Sixteen ounces 
of blood were taken from him, without any benefit ; in the course of the day, the 
vertigo went on increasing ; and towards four o'clock in the evening, he fell 
deprived of consciousness. On the following morning, he presented ail the symp- 
toms of an attack of apoplexy ; absolute loss of intelligence ; profound coma ; 
gênerai insensibility ; respiration stertorous : he died in the evening. 

Post mortem. General injection of the méninges ; rose-coloured hue of the 
grey substance of the circumvolutions. An immense effusion of blood occupied 
the middle part of the left hémisphère of the brain ; the corpus striatum and optic 
thalamus were affected by it, and the blood forced its way into the corresponding 
latéral ventricle. Septum intact ; no appréciable altération in the right cérébral 
hémisphère ; we were astonished at this ; as we here sought for the cause of the 
old hemiplegia of the left side, and of the other symptoms experienced previously 
to the récent attack of apoplexy. 

This cause, however, existed elsewhere ; in the centre of the left hémisphère of 
the cerebellum we found a yellowish softening about the size of a nut. In some 
points this softening exhibited a reddish tint ; around it the substance of the cere- 
bellum was not more injected than elsewhere. Considérable infarction of the 
lu.^gs. 

Remarks. — This case resembles the preceding in several respects ; the com- 
mencement was the same, as were also the symptoms. In the two cases, the intel- 
ligence was intact ; in both the power of motion was lost in the limbs opposite to 
the hémisphère of the cerebellum w T here the softening was, and in both the hemi- 
plegia was established gradually ; but in the first case there was but mere para- 
lysis ; in the second, there was at the same time contraction of the limbs ; and 
observe that, in this second case only, some of'the softened points exhibited a red 
tint. In thèse two cases, in a word, there existed pain of head at the commence- 
ment, the seat of which corresponded tothat of the disease. Here, however, there 
was not blindness as in the first case : did that dépend on this circumstance, that 
here the softening was less extensive, and on this also, that it affected particularîy 
the portion of the lobe of the cerebellum which is specially related to the tuber- 
cula quadrigemina ? 



DISEASES OF THE ENCEPHALON. 



205 



There is another point of resemblance between thèse two cases vvith respect to 
the manner in which the disease terminated. In both it vvas of the brain affec- 
tion the patients died, there having been congestion of this organ in the first, and 
in the second a hemorrhage which was itself preceded by cérébral hyperernia, 
which was not subdued by bloodletting. It is remarkable that the apopîectic 
attack occurred a few hours after the bloodletting. 

Case 3. — Sudderi loss of consciousness, and of motion of the extremities of the 
left side — Re-establishment of the intelligence — At the end of nine days, a new 
attack of apoplexy and death — Considérable softening of the right hémisphère of 
the cerebellum. 

Ashopkeeper, twenty-nine years of âge, was in the habituai enjoyment of good 
health, One morning, having breakfasted as usual, and being engaged in his 
shop, he suddenly uttered a loud cry, put up his hand to his head, and fell to the 
ground deprived of consciousness. For the first few minutes after this, his four 
extremities were agitated with convulsive movements ; then they disappeared, 
and the patient remained in a stupor : he was bled. After about three quarters 
of an hour, the stupor ceased ; the patient came to himself ; he recovered his 
consciousness ; speaks freely ; has no recollection ; but the entire left side of the 
body was deprived of motion. Thirty-six hours after the attack, he was removed 
to the Maison de Santé, and presented the following state :— 

Face pale ; complète paralysis of the two extremities of the left side ; no 
contraction of the limbs ; diminution of the sensibility in the paralysed limbs ; 
intelligence clear ; speech free ; no pain of head : puise free from frequency ; 
respiration natural. 

Hemiplegia was then here the only phenomenon ; during the seven days fol- 
lowing, no new symptom was observed ; but at the end of this time, the severe 
symptoms exhibited by the patient, at the commencement of his affection, reap- 
peared ; the same loss of consciousness ; the same convulsive movements ; thèse 
were of short duration ; but the stupor which succeeded them was not temporary 
as the first time ; it became, on the contrary, more and more profound ; the 
respiration became embarrassed, and the patient died in coma. 

Post mortem. We found in the nervous centres no other change than con- 
sidérable softening of the right hémisphère of the cerebellum. More than two- 
thirds of this hémisphère no longer existed except in the form of a bouillie, the 
colour of which varied according to the points examined. The softened mass 
presented in no part any effused blood. 

Remarks. — This case differs from the two preceding, both in the nature of the 
symptoms, and in their mode of development. Here, in fact, the paralysis was 
established suddenly ; it attained ail at once its highest degree of intensity ; the 
disease commenced by a complète loss of consciousness, accompanied with con- 
vulsions. At first it might hâve been taken for a fit of epilepsy, and what might 
have strengthened one in this opinion was, that at the end of a very short time, 
the intelligence returned, without the patient retaining any recollection of what 
had passed. Ail that remained of the serious symptoms was the hemiplegia ; but 
we have more than once seen epileptic patients, who, after each fit, also remained 
paralysed on one side of the body for a certain time. This hemiplegia still con- 
tinued in ail its intensity, when, at the end of eight or nine days, there came on a 
second attack, which, also, in its symptoms very much resembled those of epilepsy. 
This second attack was fatal. Nothing certainly in this case could have enabled 
us to foresee the seat of the morbid change which caused ail thèse symptoms ; even 
the pain in the occipital région was here wanting, which existed in cases 1 & 2. 



206 



CLINIQUE MÉDICALE. 



Case 4. — Pain in the occipital région — Convulsive agitation of the limbs — Dijjiculty 
of respiration — Softening ofthe left hémisphère qfthe cerebellum. 

A groom, aged nearly forty years, had always enjoyed good health, when he 
was seized with violent pain of head accompanied with dizziness : a bleeding, a 
few days after, diminishcd, without, however, removing thèse symptoins, and he 
remained the fifteen days following with headach, vertigo, and a feeling of debilitv 
which prevented him frorn working as usuaî ; his appetite, also, was somewhat 
inipaired. After this time a more serious state suddeniy set in ; the pain which 
till then occupied the entire head, was concentrated towards the occiput, and 
became at the same time much more acute ; he kept to his bed, and after having 
been bled again, he was conveyed to the Maison de Santé, where he presented 
the following state : — 

He answered questions with some difficulty, as one who scarcely understood 
what was said to him ; in other respects his answers were rational ; when asked 
where he felt pain, he pointed his hand to the occiput, and more particularly 
towards the left side of this bone ; he moved his four extremities with equal 
facility, and the sensibility in them was not changed. Vision was much weaker 
on the right than on the left ; there was no différence, however, between the two 
pupils. Puise not fréquent. Thirty leeches were applied to the base of the 
occipital bone, and a purgative was administered. 

The three days following, the patient was in a state of continuai agitation ; the 
motion of the limbs, both on the right and left, were at times so sudden and irre- 
gular, that they appeared to be convulsive. He constantly complained of his 
head, and directed his hands incessantly to his forehead. The respiration, which 
was calm on the first day, became very much impeded ; it was performed as it 
were in jerks, and it would appear that the muscles destined to exécute this func- 
tion participated in the convulsive movements of those of the limbs. He soon died 
in a state of asphyxia. 

Post mortem. Méninges injected ; nothing particular in the hémisphères of the 
cerebrum ; a small quantity of sérum in their ventricles ; reddish softening of the 
left hémisphère of the cerebellum in its posterior and inferior half. 

Remarks. — Here is a case in which the softening of the cerebellum presented 
itself to us with symptoms very différent, in certain respects, from those observed 
in the three preceding cases. Here there is no paralysis, and the only change 
noticed in the power of motitm, was that singular and irregular agitation of the 
limbs, both on the right and left side. But here again, we find the occipital pain 
which also existed in cases 1 and 2, and still further, vision was weakened in the 
eye opposite to the affected lobe of the cerebellum, an important fact, since we 
find it in several cases of affection of the cerebellum. Another phenomenon 
deserving of remark, was the embairassment of the respiration. There was a direct 
influence exercised in this function, or, at least, on the muscles which serve to 
perform it, by the morbid state of the cerebellum. 

The four cases now cited, bear a strong resemblance to those which have been 
already published by différent authors, and the différences which they presented 
to us with respect to the nature of the symptoms are also found in the latter. We 
shall now présent an analysis of thirteen cases, four of them belonging to ourselves ; 
namely, — the four preceding cases ; and nine of them having been collected by 
others *. 

In thèse thirteen cases, the intelligence presented the following state : — Several 

* Parent-Duchatelet et Martinet, Traité sur P Aracîinitis, p. 420. Rostan, Ramollissement 
du Cerveau, 2nd Edit. p. 143. Lallemand, Maladies P Encéphale, Lettre ii. p. 34. ; Lettre 
v. p. 330. Serres, Anatomie du Cerveau, torn. ii. p. 616 (Deuxième Observation). Cham- 
beyron, Thèse. Dany, Mémoires de Médecine Militaire, tom. xxii. p. 379. Monod, Nouvelle 
Bibliothèque Médicale, 1828,t om. iii. p. 74. 



DISEASES OF THE ENCEPHALON. 



207 



times, it continued always intact. One time, being at first intact, it became dis- 
turbed towards the end, and some delirium came on during- the last twenty-four 
hours ; but in this case, which is our first, there was found, on examining the body, 
considérable injection of the membranes and of the cérébral substance. On two 
other occasions, the intelligence, without being lost, became dull, as occurred in 
the subject of our fourth case, and in another quoted by M. Monod. On three 
other occasions the disease commenced with sudden loss of consciousness. At 
another time it was some days after the attack of a continued fever that the patient 
fell into coma. 

In two cases the speech was altered ; it was not lost, but merely became em- 
barrassed in the subject of M. Monod's case ; it was, on the contrary, completely 
lost in a case cited by M. Lallemand, and in this case, the cerebellum was the 
only part of the nervous centres appreciably altered. 

Whilst the changes of intelligence were variable, inconstant, and of little 
importance, the lésions of motion, on the contrary, were observed in ail the cases 
except one ; and again, in this case it is not quite certain that motion was not 
interfered with ; it is there said that the patient fell into coma ; but there does not 
appear to be anything certain with respect to the state of the limbs, and, besides, 
this case leaves some doubts regarding the nature of the altération of the cerebellum. 

There remain then twelve cases, out of thirteen, in which the power of motion 
is evidently changed. 

In two cases, the altération consisted in a sort of convulsive agitation of the 
limbs, this agitation being equal on both sides ; one of thèse cases forms the subject 
of our fourth case, the other is detailed by M. Monod. 

Finally, in the ten other cases, the existence of paralysis was ascertained, either 
simple, or with contraction of the parts deprived of voluntary motion. 

Out of thèse ten cases, the lésion of motion was observed nine times in the 
limbs of the side opposite to the hémisphère of the cerebellum, where the softening 
took place— once it was found to have taken place on the same side as the soften- 
ing. This exceptional case was published by M. Rostan. It was that of a woman, 
sixty-three years of âge, who entered the infirmary of the Salpêtrière to be treated 
for pneumonia, of which she died. This woman had, for a long time back, the 
right arm contracted, and could not perform any motion with it ; the three other 
extremities had preserved their natural motion. This paralysis was established 
gradually, and had been preceded by a numbness which occupied successively the 
hand, fore-arm and arm. The autopsy showed no altération in the nervous centres 
but the following : — The lower part of the right side of the cerebellum, near the 
annular protubérance, presented a dépression produced by an exostosis which 
occupied the corresponding part of the petrous portion of the temporal bone, and 
of the portion of the occipital which is articulated with it. The substance of the 
cerebellum in contact with this exostosis was softened. 

Is it in conséquence of its particular seat, that in this case the softening of the 
cerebellum gave rise to a paralysis on the same side with it, or may it not be 
asked whether the lésion of the cerebellum was really here the cause of the 
paralysis, for the vertébral canal was not examined ? Now, might it not have 
happened that another exostosis was developed on a point of the parietes of this 
canal, and that by compressing the part of the spinal marrow on the right, it 
really was the cause of the paralysis of the right side ? 

In ail thèse cases, besides, the paralysis most frequently attacked the two ex- 
tremities of one side at once. Sometimes it was established suddenly; sometimes, 
on the contrary, it commenced by a slight weakening of the limbs, which increased 
progressively. 

The paralysis of the extremities was but very rarely accompanied by paralysis 
of other parts of the body ; once only there was observed a paralysis of the face, 
which took place on the same side as that of the extremities. How shall this 



203 



CLINIQUE MÉDICALE. 



fact be explained by our présent knowledge of anatomy. This case was pub- 
lished by M. Lallemand *. The subject of it suddenly lost consciousness : on 
coming to himself, he had hemiplegia of the right side, and the commissure of the 
lips was drawn te the left. A softening of the white substance of the left lobes 
of the cerebeilum was observed, and no other lésion. 

Strabismus was remarked in onîy one case : it took place on the side opposite 
to the softening. 

The sensibility presented several altérations, but none of them were constant. 

At flrst several patients complained of a pain, the seat of which corresponded 
exactly with that of the lésion ; this pain had its seat at the occiput, but it was 
entirely wanting in more than one case. 

The cutaneous sensibility presented the same inconstancy of altération as in 
the case of softening of the cérébral hémisphères ; sometimes it was abolished, 
and sometimes more acute than usual ; sometimes it continued in its normal 
state. In the case in which coma existed, the entire skin was insensible ; except 
those cases, the loss of sensibility existed only in the paralysed limbs. 

Once only that same insensibility of the conjunctiva was observed which is 
found to exist in cases where the fifth pair of nerves is affected ; at the same lime, 
says M. Lallemand, to whom we are indebted for the knowledge of this fact, the 
eye was as it were withered-j\ What connexion, then, unités certain fibres of 
the cerebeilum to the fifth pair ? 

Digestion, circulation, and the différent sécrétions presented nothing remark- 
able. In some cases the respiration was very much modified, as may be seen in 
our fourth case. 

With respect to the génital organs, there is référence made oniy to one of the 
thirteen which form the subject of our analysis. This case was published by M. 
Dany : the patient, says this physician, continually applied his hand to the testicles, 
though thèse organs presented no trace of suffering. 

In ail that has been said, there is as yet mention only of the cases in which one 
of the latéral lobes of the cerebeilum was alone softened. Let us now consider 
the cases in which the softening affected the entire cerebeilum. Only three cases 
of this kind have been published to our knowledge. 

In one of those three cases the individual, who was a child of fourteen months 
old, was attacked with epileptic fits, in which he died. During his illness it was 
noticed that the pénis was in a state of half-erection. The cerebeilum was 
softened and diffluent at its base on both sides. But the same softening affected 
the upper portion of the spinal marrovv. 

In the second case$ an erotic delirium was observed with the phenomenon of 
érection. The author of this case states, without more détail, that the grey sub- 
stance of the cerebeilum was everywhere softened. Was it only the external grey 
substance ? 

In the third case |j phenomena of an entirely différent nature took place. The 
patient evinced an extraordinary tendency to fall back ; when he sat down, he 
could not rise without much difficulty ; one time when in the erect posture, the 
first movement of his feet was in a latéral direction, without his leaving the place 
where he was. In order to change place, he directed his feet from before back- 
wards : he assured us that an irrésistible force obliged him to go backwards. In 
this case the lésion of the cerebeilum was much more considérable than in the two 
pceceding cases ; it was, in its entire extent, changed into a whitish bouillie, where 
there was no longer discovered any trace of organisation. Thus the functional 
disturbances occasioned by softening of the cerebeilum vary according to the 
greater or less extent of this softening, and to the parts affected, 



* Loc. Cit., Lettre ii. p. 134. f Lallemand, Lettre ii. p. 134. 

"t Revue Médicale, tom. i. p. 338. $ Archives Générales de Médecine, toin. xxii. p. 133 
|| Journal de Physiologie Expérimentale, &c. tom. vi. 



DISEASES OF THE ENCEPHALON. 



209 



SECTION III. 

ACCIDENTAL PRODUCTS DEVELOPED IN THE CEREBELLUM. 

Case 1. — Cyst filled with pus in the centre of the left hémisphère of the cerebellum — 
Pain at the base of the occiput — Paralysis, with contraction of the extremities of 
the right side — Convulsions at intervais — Intelligence free. 

A girl, nineteen years of âge, was paralysed in the entire of the right side of 
the body, when she was admitted into the Hôpital Cochin. The upper extremity 
struck with paralysis, was at the same time very much contracted, and she experi- 
enced acute pains in the part from time to time. She also felt, towards the upper 
part of the nape of the neck, acute lancinating pains, which returned occasionally. 
In the interval between them, she felt towards the same part a dull pain, which 
seemed to her to lessen when she inclined the head forwards, and a little to the 
left ; she usually kept in this position. She told us that she first began to feel 
pain in the back part of the head, and that some little time after the extremities 
of the right side lost the power of motion. Ail this time amounted to about five 
weeks. The intelligence was clear. 

A little time after her admission, the pains of the occiput and back part of the 
neck became more and more acute, and convulsive movements were soon added ; 
thèse always commenced by a violent shaking of the head, which was inclined 
backwards, as in a variety of tetanus. On some days the convulsions were con- 
fined to this part ; at other times they became gênerai, and almost ail the muscles 
of the body became affected. Consciousness was still preserved. 

However, the convulsions went on increasing both in frequency and intensity; 
they extended to the respiratory muscles, and she died in a state of asphyxia. She 
vomited frequently towards the close, 

Post mortem. The left hémisphère of the cerebellum was occupied some lines 
beneath its upper surface by a cyst as large as a pullet's egg, filled with greenish 
pus ; the parietes of this cyst, formed of a sort of cellulo-fibrous tissue, were about 
a line in thickness. Around it the nervous tissue was healthy. 

Remaries. — This case of encysted abscess of the cerebellum resembles very 
much, with respect to the symptoms, some cases of softening of the cerebellum 
detailed above. We find here both the occipital pain and the paralysis, the seat 
of which is always opposite to that of the lésion. Here also, as in several of thèse 
cases of softening, the intelligence remained intact. But there is in this case a 
prevailing phenomenon : that is, the convulsions, the constantly increasing inten- 
sity of which always ends fatally. The vomiting observed towards the close was 
not connected with any morbid change of the stomach ; like the convulsions, in 
the nature of which they participated, they were the resuit of the disturbance of the 
innervation. 

This abscess formed slowly, and did not succeed to any acute disease, nor was 
it caused by external violence. 

Let us now try to connect with this case some other cases of abscess of the 
cerebellum, published by différent writers. 

The cases of this kind which we have been able to collect amount to eleven. 
In eight of them the abscess occupied one of the latéral lobes of the cere- 
bellum ; in two others the suppuration occupied the two lobes ; and in one case 
only it was the rniddle lobe that was affected. 

The analysis of thèse eleven cases and of our own gives the folio wingresults : — 
The intelligence was not disturbed in any case, except sometimes at the end : in 
several cases it is said the patients die possessed of ail their consciousness. In 
the individual who forms the subject of one of Dr. Abercrombie's cases, continuai 

p 



210 



CLINIQUE MEDICALE. 



drowsiness was observed ; but the patient could be easily aroused from it, and 
then he enjoyed ail his intelligence. 

The power of motion rernained intact in six cases. In five of them one of the 
latéral lobes of the cerebellum was the seat of the abscess ; in the sixth it was the 
middle lobe. 

Paralysis took place in three cases, but with particular circumstances in earh 
of them. 

Thus, in the case above recorded, there was hemiplegia with contraction on the 
side opposite to the diseased lobe cf the cerebellum. 

In another case, quoted by Borsieri from Plancus, there was also hemiplegia, 
but on the same side as the abscess of the cerebellum*. This case would form 
the second exception which we meet to the law of the crossing influence of the 
hémisphères of the cerebellum : the first exception was furnished by M. Rostan. 

In a third case, cited by M. Larrey, the paralysis at first affected the two lower 
extremities ; and subsequently it became gênerai. In this case the suppuration 
attacked the two lobes of the cerebellum at once. 

A remarkable altération of motion was noticed in M. Lallemand's case. The 
patient staggered on his legs. In this case, the only one which tends to con- 
firai the opinion of the physiologists, who assign to the cerebellum the province 
of regulating motion, the cerebellum was converted into a pouch full of pus. 

To complète the table of the différent disturbances of motion which took place 
in the twelve cases of abscess of the cerebellum now analysed, in the case of 
Piancus already cited, there was a well-marked trismus, and in one of Abercrom- 
bie's cases, where the abscess occupied but one of the lobes of the cerebellum, 
strabismus was observed. 

Such are the différent disturbances affecting motion in thèse twelve cases : let 
us now see what were the disturbances of sensation. 

In only one case (and that was seen by ourselves) the limbs, but only those 
which were paralysed, were the seat of acute pains. In no other case was the 
sensibility affected. 

In nine cases there was pain of head ; and in ail it was remarkably severe ; 
sometimes it was continued, sometimes intermittent. Four times the seat of this 
pain was not determined ; three times it occupied the occipital région ; twice the 
frontal and occipital régions, alternately in one case, simultaneously in the other ; 
once it was confined to the anterior part of the head. 

In only one case was there blindness ; it was in the person seen by Gall, in 
whom the two lobes of the cerebellum were in a state of suppuration. But observe 
that Gall adds, that the commissure of the two lobes of the cerebellum (pons 
Varolii) was very much atrophied, and of a yellowish colour. Now did not the 
morbid state of this part involve the fifth pair of nerves ? 

In nearly half the cases, there was observed either nausea or vomiting. Thèse 
phenomena were not a mere complication ; they were certainly connected with 
the affection of the cerebellum. 

The generative functions presented nothing particular, except in one case. It 
was that recorded by Gall, in which the suppuration attacked the two lobes 
of the cerebellum. The subject of this case was a boy thirteen years old, who 
gave himself up furiously to onanism. 

Among thèse twelve cases, there are some in which the affection presented the 

Dextrum cerebelli lobum nbseessu magnain partem cormptum vidit Cel. Lanus Planous 
Ariminensis in nobili puero, qui a suppresso puris ex anre ejusdem lateris fluxu, cui a primis 
usque annis obnoxius fuit, inciderat in acerrimatu cepbalalgiam cum febre continua acutâ, ex 
quâ intra brève temporis spatium rnortem oppetiit. Febris pluries intra diem exacerbatur, et 
b/mifica erat, sic ut hemitritseo similis videretur. Accedebat subinde aphonia et trismus, sed 
brevi adibat loquendi potestas. Tandem par al y si non oppositi, ut morts est, sed ejusdem 
lateris correptus, sensïbusque orbatus fato cessit. 



DISEASES OF THE ENCEPHALON. 



211 



commencement and progress of acute inflammations ; in others, on the contrary, 
the suppuration took place imperceptibly without the symptoms of an acute affec- 
tion having been observed at any period. In cases of this latter kind, the duration 
of the disease was sometimes very long. 

Case 2. — Ttiberculous mass in the left lobe of the cerebellum — pain of head — Hemi- 
plegia on the left side — Blindness — Intelligence retained. 

A laceman, aged twenty-nine years, presented the foilowing state :— such a 
weakness of sight that he could scarcely distinguish day from night, and still con- 
sidérable contraction of the two pupils ; naturai sensibility of the face still preserved ; 
pain ail over the head, but more acute towards the occipital région ; hemiplegia 
of the left side complète, without contraction, or modification of the sensibility of the 
paralysed limbs. Nothing remarkable in the movements of the tongue ; intelli- 
gence perfect ; fréquent cough ; some dyspnœa ; pale and emaciated ; subject to 
diarrhœa. He entered the La Charité, where for the flrst fifteen days he com- 
plained of nothing additional, except that during this time he had diarrhœa, for 
which leeches were applied to the anus. He told us that, for about the last three 
years, he had a very painful headach, intermittent at flrst, and which subsequentlv 
became continued; he also states that, during this time, he gradually lost the 
power of seeing, and that of motion in the extremities of the left side ; still fur- 
ther, about two years ago, he continued struck for the space of three months with 
complète insensibility of ail the left side of the face ; then he no longer had any 
taste for food, and the mucous membrane lining the interior of the left cheek 
seemed to be separated, as if by a pièce of linen, from the objects brought in con- 
tact with it. He always continued to hear equally well with both ears. 

After a fortnight's stay in the hospital, he was carried off in less than three days 
by an acute peritonitis. 

Post mortem. Cranium. — Nothing remarkable in the cerebrum. But on view- 
ing the cerebellum externally, its right lobe was observed no longer to have its 
usual form ; it was marked with eminences (bosselé), and its laminœ no longer 
have their ordinary direction, nor their naturai relations ; several were effaced. 
We scarcely penetrated some lines in depth, wnen in the inner half of this lobe, 
and in ail its height, we find, instead of the tissue which should form it, a hard 
substance of a yellowish white colour, possessing ail the characters of tubercular 
matter ; there was no softening in any part. 

Thorax. — Some miliary tubercles were scattered throughthe two lungs. 

Abdomen. — The peritoneum was filled with a purulent liquid. A great number 
of small white bodies raised the mucous membrane of the ilium, and resembled so 
many tubercles. Small ulcérations were found towards the end of this intestine, 
one of which established a communication between the interior of the intestinal 
canal and the peritoneum ; whence the peritonitis. The spleen also contained 
some tubercles. 

Remaries. — A pain, the principal seat of which was conformable to that of the 
lésion, paralysis which took place on the side of the body opposite to the latter, and 
the loss of sight, such were the symptoms here accompanying the development of 
the tubercular matter in one of the latéral lobes of the cerebellum. They are the 
same symptoms as those occasioned by the différent affections of the cerebellum 
already described, only here they are developed very slowly, and continue 
much longer. In the midst of ail this disturbance, the intelligence remained 
intact. With respect to the extraordinary loss of sensibility, observed for the 
space of three months in the left side of the face, and which was accompa- 
nied by the complète abolition of the sensé of taste, could this have been 
occasioned by a temporary affection of the fifth pair of nerves ? 

There were tubercles in several other organs also, as weil as in the cerebellum. 
Those contained by the lung confirm the law laid dowu by M. Louis. 



212 



CLINIQUE MEDICALE. 



Case 3. — Several tubercles in the right lobe of the cerebellum — Occipital headach — 
Vomiting — Putmonary phthisis. 

A man, twenty-three years of âge, entered the La Charité, with the ordinary 
symptoms of pulmonary phthisis already far advanced. This man was also tor- 
mented for more than a year by a fixed pain seated in the occiput, more par- 
ticularly towards the right side of this bone. This pain, which was usually dull, 
became occasionally very acute. Besides, the patient for some months back was 
annoyed with vomiting, which was frequently repeated ; this vomiting always came 
on whenever the headach became more intense ; it returned even without such 
an occurrence ; tolerable appetite ; no pain in the epigastrium ; appearance of the 
tongue natural ; diarrhœa ; he died of phthisis, without presenting any new 
svmptoms referrible to the nervous centres. 

Post mortem. Five tubercles in the right lobe of the cerebellum, three of which 
were of the size of a common pea, another that of a hazel-nut, and another that of 
a chestnut at least. None of them were softened ; between them the tissue of the 
cerebellum was healthy : two of thèse tubercles were situated near the upper 
surface of the organ. and the others were developed in the very centre of the lobe 
of the cerebellum. 

Thorax. — Cavities and numerous tubercles in the two lungs. 

Abdomen. — Stomach healthy ; ulcérations in the intestines. 

Remarks. — Very différent from the preceding, this case présents to us an 
instance of tubercles of the cerebellum announced by very few symptoms. The 
pain of head is the only phenomenon, the old and constant existence of which 
announced a lésion of the encephalon ; motion remained perfectly intact. The 
vomiting we thiuk connected with the disease of the cerebellum. On the one 
hand, no lésion of the stomach accounted for it, and on the other haud, we have 
seen this same symptom supervene in several other cases of disease of the 
encephalon in gênerai, and of the cerebellum in particular. We have even seen 
cases in which, either for the entire duration of the disease, or in some of its 
periods, vomiting was the only phenomenon which we could connect with the 
cérébral affection, so that the latter leaving intact the différent functions of the 
life of relation, confined itself exclusively to the stomach, whose action it dis- 
turbed, Dr. Abercrombie was so struck by the frequency of such an occurrence, 
that in his treatise on diseases of the brain, he has ranged under a particular head 
a certain number of cérébral affections of a very différent nature, but which ail 
resemble each other in this, that the prevailing symptoms to which they give rise 
are referrible to the digestive organs. 

There are cases also where thèse symptoms are quite concealed, where the 
headach itself does not show itself, and in which there are discovered in the 
cerebellum tubercles more or less numerous, without there having existed during 
life any disturbance on the part of the nervous centres ; similar cases are not rare, 
particularly in children. We have met a case of a boy ten years old, who died of 
phthisis, and who never complained at ail of the head, yet the left lobe of the 
cerebellum contained four tubercles. 

Thèse cases remind us of another which was very remarkable, and in which no 
symptom was observed on the part of the nervous centres, though an important 
part of thèse centres was the seat of a well-marked cancerous dégénérescence. 

The individual who formed the subject of it was a woman, forty years of âge, 
who died of cancer of the utérus, without having ever presented any symptoms but 
such as usually attend this affection ; the cancer was confined to the neck of the 
utérus. The portion of the medulla oblongata fowning the anterior wall of the 
fourth ventricle, and which constitutes the posterior part of the great commissure 
of the cerebellum, immediately behind the tubercula quadrigemina, and as far as 



DISEASES OF THE ENCEPHALON. 



213 



the anterior extremity of the corpora restiformia, was changed into a tissue 
similar to that occupying the neck of the utérus. 

Case 4. — Extraordinary sensibility ofthe skin of the trunk and extremities — Paralysis 
ofone ofthe sides ofthe face — Two tubercular masses, one of which was seated 
in the left lobe of the cerebellum aud the other in the vertébral canal — Pulmonary 
phthisis. 

A boy, seventeen years of âge, presented ail the signs of pulmonary phthisis, 
when he was received into the La Charité. He also exhibited some symptoms 
which indicated a serious lésion of the nervous System. His state was as 
follows : — 

Habituai rétroversion of the head ; it could, however, be easily brought 
forward, but if left to itself, it soon resumed its former position. The extremities 
retained ail the freedom of their motions ; the sensés were intact ; but the moment 
any point of the skin was touched, whether of the limbs or trunk, he experienced 
a very painful sensation ; ail the motions of the arms and legs were accompanied 
with a sort of pain, which the patient compared to that which is felt when one is 
fatigued. Ail the left side of the face was struck with the most complète immo- 
bility ; neither the cheek, eyebrow, nor skin of the forehead on this side could be 
at ail moved, and the right commissure of the lips was drawn up very much. 
The left eye always open, could not be shut at the wifl of the patient ; the con- 
séquence of this was redness of the conjunctiva of this side ; thèse différent 
symptoms existed for several months in ail the paralysed side ; the sensibility was 
retained. 

This patient died in the course of pulmonary phthisis, without having presented 
any new phenomenon on the part of the nervous System. 

Postmortem. Cranium. — The sub-arachnoid cellular tissue was infiltrated with 
a certain quantity of limpid sérum ; this same sérum fîlled the ventricles ; the left 
lobe of«the cerebellum was occupied, not far from its outer edge, and at nearly an 
equal distance from its upper and lower surfaces, by a tubercle about as large as a 
nut — this tubercle was not softened. On the level of the first and second cervical 
vertébrée, the spinal marrow was separated from the vertébrée by a tubercular mass 
developed in the méninges, not large enough, however, to make any considérable 
pressure on the spinal marrow. 

The lungs contained numerous tubercles in ail stages. The intestines were 
ulcerated. 

Remarks. — Here again was a case in which the small tubercle, developed in the 
cerebellum, remained completely latent. There were, in fact, but two symptoms 
which indicated the affection of the nervous System : the first was the facial 
paralysis, and the second the cutaneous hyperaesthesia *, accompanied with pain in 
muscular contraction. Now, the paralysis of the left side of the face does not 
seem to us to have been caused by the altération of the cerebellum, but, perhaps, 
by an affection of the portio dura of the seventh pair of nerves. Perhaps there 
was also a tubercle, which, developed in the bony canal where this nerve is 
inclosed, had made pressure on it. 

With respect to the great increase of sensibility exhibited by the skin of the 
trunk and limbs, with the production of pain whilst the muscles of thèse limbs 
were contracting, it seems to us a matter of doubt whether this phenomenon 
depended on the lésion of the cerebellum. We are well aware that some cases 
have been cited in which the changes of this organ have been followed by similar 
phenomena. Here,besides, there was another lésion, which, in our opinion, was more 
probably the cause of the extraordinary exaltation of the sensibility : that was the 

* Hyperaesthesia, excessive sensibility, from farep, and uiaGavo/xat, to feel or perceive. — Ta. 



214 



CLINIQUE MÉDICALE. 



tubercular mass developed between the upper extremity ot the spinal marrow, 
and the posterior wali of the bony canal inclosing it ; it was then the posterior 
surface of the spinal marrow, which was in contact with this morbid product, that 
is, the part of this organ, which the experiments of M. Magendie warrant us in 
regarding as the spécial agent of sensibility. But if the tubercular mass had 
increased, a time would have arrived when it would hâve corapressed the spinal 
marrow, instead of irritating it by its mere contact ; and then the sensibility, at 
first exalted, would have been destroyed. 

Case 5, — A cyst filled ivith ossiform concrétions in the right lobe of the cerebeUum. 

A female child, twenty months old, exhibited no cther symptom during her stay 
in the Hôpital des Enfans, than a constant moving of the head, by which this part 
was continually balancing from right to left and from left to right. In other 
respects the child seemed to évince as much intelligence as other children of the 
same âge ; her sight was good, and the motions of the limbs free ; countenance 
pale. She died of severe diarrhœa. 

Post mortem. The centre of the right lobe of the cerebellum was occupied by 
a cyst the size of a nut, which contained a great number of small concrétions of 
irregular forms, and hard as bone : they were immersed in a gelatinous kind of 
liquid : around them the nervous substance underwent slight softening. 

Several of the circumvolutions of the convexity of the cérébral hémisphères were 
considerably hardened. 

Remarks. — A considérable number of cases have been recorded relative to 
tumours of différent kinds developed in the cerebellum and around it, and which. 
in either situation, must exercise an influence on the fonctions of this organ, 
whether it be irritated, compressed, or disorganised by thein. 

We have found scattered, in différent works, thirty-one cases of this kind. In 
ail thèse cases, the tumours formed in the cerebellum or in its membranes, were 
sometimes cysts containing solid or liquid substances of différent kinds, sometimes 
fibrous masses, sometimes tubercular or cancerous products. 

In the great majority of thèse cases, the intelligence was preserved intact during 
the entire course of the disease ; only that frequently a few days before death a 
state of coma was observed, which sometimes might be accounted for by considér- 
able injection of the entire encephalic mass, or by the présence of a great quantity 
of sérum in the ventricles ; sometimes no lésion was fourni which could account 
for it ; in the latter case it is probable that a moment arrives, when, either by its 
greater deveîopment, or by the sole fact of its prolonged existence, the affection 
of the cerebellum will produce a reflected effect on the rest of the encephalon, and 
seriously disturbs its functions ; for there is certainly a consent of action between 
ail the parts of the encephalon, and one of them cannot be for any time altered 
without the others ultimately feeling it. 

Seven patients only, out of thirty-six, presented, long before death, a marked 
disturbance of the intelligence. 

One of thèse patients, a female, thirty-five years of âge, was an idiot from birth. 
The right lobe of the cerebellum was compressed by a tumour which had its 
origin in the occipital fossa. It might be supposed that the idiotcy was caused 
by the embarrassment of the cérébral circulation ; but, is it probable that this 
tumour existed from birth '? Now, the absence of intelligence was dated from this 
period. It is not, then, probable that, in tbis case, the lésions found in the 
cranium were the cause of the idiotcy. 

Another patient exhibited a loss, at first temporary, but afterwards permanent, 
of the memory of words. There was found in this individual an encephaloid 
tumour in the centre of the right lobe of the cerebellum, nearer the lower than the 
upper surface. A great quantity of sérum also distended the latéral ventricles. 

In three other patients, a gênerai weakness of intellect was noticed. In one of 



DISEASES OF THE ENCEPHALON. 



215 



thern the rightlobe of the cerebellum was compressée! by a tumour which belonged 
to the dura mater ; some sérum dilated the ventricles. In the second an 
encephaloid mass seized on the posterior and inferior part of the cerebellum, as 
well as the medulla oblongata. In the third, a tubercle of an inch and a half in 
diameter was developed on the upper surface of t*he cerebellum, in the médian 
line. 

In a seventh patient, some delirium was observed. Did this delirium, which 
was of short duration, dépend on the tubercles found in the left lobe of the 
cerebellum ? Was it not rather the resuit of the injection which was detected in 
the pia mater of the base of the brain ? Such are the only cases in which the 
intelligence presented any perceptible disturbance. The disturbances of motion 
are much more fréquent. 

Out of our thirty-six cases, there are but eight in which motion was not in some 
way disturbed. 

Complète or incomplète paralysis was observed fifteen times. 

In this number there were but four who had hemiplegia ; it took place on the 
side opposite to the lésion of the cerebellum in three cases, and in a fourth the 
two lobes were diseased. 

Paralysis was also observed four times. In thèse four cases the cerebellum was 
compressed or disorganised, either in its two latéral lobes at once, or in its middle 
lobe. In one of thèse cases the medulla oblongata participated in the altération 
of the cerebellum. It is remarkable that in thèse four cases the paralysis partîcu- 
larly affected the lower extremities, whilst the upper extremities enjoyed ail their 
freedom of motion, or else had undergone only a debility ahvays less than the lower 
extremities. 

Two patients presented a paralysis, or at least a considérable debility of the four 
extremities. In one of them, a tubercular mass, developed at the base of the 
cranium, compressed at once the cerebellum and spinal marrow ; in others the 
two latéral lobes of the cerebellum contained tubercles, but they were twice as 
large in the right lobe as in the left ; and the feebleness of the limbs was greater 
on the left than on the right ; so that this case of gênerai paralysis may again serve 
to prove the crossing influence of the lobes of the cerebellum. 

The paralysis of the face, which we met once in one of the cases belonging to 
ourselves, isolated from every other paralysis, was connected with the existence of 
two tuberculous masses ; the one developed on the left lobe of the cerebellum, 
and the other at the posterior surface of the spinal marrow. 

There remain four patients, of whom nothing else is said with respect to motion 
except that they graduaUy become debilitated. 

Involuntary contractions affecting a greater or less number of muscles were 
observed more frequently than paralysis ; we met twenty-two cases in which thèse 
contractions were found to exist. In fifteen of thèse twenty-two cases, the entire 
body was agitated at intervais by convulsive movements, which became more 
and more fréquent, and it was often in the midst of violent convulsions that the 
individuals died. Some, and that was the greatest number, retained their con- 
sciousness during the continuance of their convulsions ; others lost it suddenly, 
and they presented the symptoms which characterise an attack of epilepsy. In 
thèse patients, the lésion occupied différent seats sometimes confined to a single lobe 
of the cerebellum, sometimes extending to the two, sometimes occupying also the 
medulla oblongata. 

The movements of the tongue were embarrassed in only two cases, and in beth 
it results from the seat of the lésion, that the nerve of the ninth pair must be com- 
pressed or disorganised by the tumor pressing on the cerebellum. 

In the thirty-six cases which form the subject of our analysis, the sensibility 
presented disturbances not less varied than the power of motion. 

The gênerai sensibility presented no disturbance in the greater number of the 



216 



CLINIQUE MEDICALE. 



cases : sometimes, however, it exhibited a remarkable exaltation, whilst, at other 
times it vvas completely abolished. 

Not merely the gênerai sensibility has been modified in some of our thirty-six 
patients ; occasionally, also, the organs of the particular sensés have been found 
affected ; thus, in one case, deafness was observed ; and in six, vision was either 
completely destroyed, or very much weakened. 

Among the organs of the life of nutrition, the stomach is the only one which 
presented a phenomenon deserving of particular notice, with respect to its fréquent 
reproduction ; this phenomenon is vomiting ; it was observed twelve times in thirty- 
six cases. 

If you now consider thèse twelve cases with respect to the nature and seat of 
the affection of the cerebellum, you will find nothing différent from what was to be 
seen in the twenty-four other cases, where there was neither vomiting nor nausea. 
A priori we should not expect to find this peculiarity of either seat or lésion ; for 
in ail this volume, in connexion with lésions the most différent, as well those of the 
méninges as those of the nervous pulp itself, we have seen vomiting show itself as 
a common effect of a crowd of affections of the encephalon. Can it be said 
that when it is proa^ced, the brain is in the same condition as when it does 
not occur ? Certainly not, for a différent effect cannot be comprehended, but 
with respect to a différent cause ; but thèse conditions we know not ; they 
escape us just as those interior changes of organisation have been removed 
hitherto from our^ researches, which changes, coming to be connected with 
identical lésions, render their effects so variable. Certainly, the inconstancy of 
the effects here can only be owing to the variety of causes. To ascertain 
those causes, it would be necessary to interrogate each cérébral fibre, first con- 
sidered separately, and then traced in its connexions with other fibres. It is in 
this double point of view, that we think the pathology, as well as the physiology 
of the brain, should be studied. It is, on the one hand, a great whole, composed 
of a number of parts, each of which performs a spécial act ; but, on the other hand, 
thèse différent parts are intimately connected with each other, so that they are 
mutually bound together. Hence it follows, that in the point where a lésion is 
discovered, the direct cause of the effects which it produces does not always 
réside, and according as it re-acts on such or such other points especially destined 
for the performance of a certain act, it is this which will be found modified. If 
then it happened that we succeeded in discovering in the encephalon a certain 
number of parts, the lésions of which always occasioned the disturbance of the 
same cérébral act, it would not, in our opinion, be fair to object to the doctrine of 
localisation, that there are also other cases where this same functional disturbance 
is reproduced, though the lésion might be elsewhere. 

Among the thirty-six cases constituting the subject of our analysis, only in three 
was any thing particular noticed with respect to the génital apparatus. In one of 
thèse cases permanent érection of the pénis was observed during the whole time 
the patient was attended. There was, in this case, compression made at one and 
the same time, by a tuberculous mass, both on the right lobe of the cerebellum, and 
on the medulla oblongata. In the second case, the patient indulged in mastur- 
bation ; several tubercles were found in the upper part of the cerebellum ; whether 
on both sides, or on one only, we are not told. Lastly, in the third case, regard- 
ing an individual said to be very prone to venereal desires, a tubercular mass 
occupied ail the substance of the middle lobe. 



DIVISION II. 



DISEASES OF THE CHEST 



FIRST BOOK. 

DISEASES OF THE HEART. 

1. Since the publication of the immortal researches of Corvisart, and of the 
numerous works which have, since his time, extended the domain of science, the 
history of diseases of the heart and its appendages should be considered as almost 
completed. In the following observations we shall call attention particularly to 
certain points of this history, which, after so many researches, still appeared 
capable of being illustrated by additional facts. 



SECTION I. 

OBSERVATIONS ON DISEASES OF THE PERICARDIUM. 

2. Most of the morbid phenomena to which acute or çhronic inflammation of 
the pericardium gives rise, seem to dépend on the sympathie disturbance, which is 
felt either by the heart or by other organs, Thèse phenomena must then be 
extremely variable with respect to their nature and their intensity ; they must 
présent as many différences as there are in the sensibility of each individual, in 
the number and activity of the sympathies of his organs. It is the same in this 
respect with diseases of the membrane covering the heart as with the membranes 
covering the ce.rebro-spinal System. It would, to be sure, be a désirable thing 
that such a lésion was always indicated by such a determinate group of symptoms ; 
but such a thing occurs in only a very small number of cases : thus to endeavour 
to connect with any lésion symptoms always identical, is to retard the improve= 
ment of diagnosis in wishing to simplify it. It would be a task at least as useful 
to endeavour thoroughly to know the symptoms, as numerous as they are varied, 
which may dépend on one and the same lésion. It is not certainly with practical 

Q 



218 



CLINIQUE MEDICALE, 



medicine as with several other branches of human knowledge, where a smaîl 
number of principles being given, nothing remains but to apply them to ail 
the particular cases. In medicine, on the contrary, where a fact is never pre- 
cisely similar to the facts already observed, it is necessary continually to in- 
dividualise, if I may say so ; in that consists the entire art of diagnosis, and thence 
it is that the well-instructed physician who has seen most, must also see best. 



CHAPTER I. 

ACUTE PERICARD1TIS 

3. The following cases are of three kinds : the first will point out inflammation 
of the pericardium announced by local symptoms, which render its diagnosis 
sufnciently easy. We shall then give other cases, in which there was no other 
local symptom than gîeater or less dyspnœa ; so that it was only by a process of 
exclusion* that the existence of pericarditis could be recognised. Finally, in a 
third class, will be found cases of a rarer description, in which the acute peri- 
carditis was not even announced by dyspnœa, and in which it produced no other 
symptom than great accélération of the puise, nervous phenomena of a severe 
kind, sudden prostration of strength, and death. 



ARTICLE I. 

CASES OE ACUTE PERICARDITIS WITH CH ARACTERISTIC SYMPTOMS. 

Case 1. — Acute articular rheumatism — Suddenly a sharp pain in the région of the 
heart — Speedy death — Purulent exudation on the internai surface of the peri- 
cardium. 

A baker, thirty-one years of âge, entered the La Charité in the course of the 
month of August, 1822. For the last fifteen days he had been affected with 
acute pains, which ran through différent articulations, and which at the time of his 
admission were seated in the articulations of the elbow and wrist of the left side, 
the right knee and foot of the same side. Ail thèse parts were swollen and red. 
Several times since the attack of this rheumatism he had severe headachs ; the 
fever was intense ; the tongue was red and a îittle dry ; the epigastrium sensible 
to pressure. Two bleedings of twelve ounces each were resorted to the first 
twenty-four hours. The coagulum of blood was covered with a thick buffy coaL 
The next day there was no perceptible amendment ; a third bleeding was ordered, 
which was buffed as the preceding ; the knee and foot of the right side ceased to 
be painful, but at the same time the left knee swelled ; the elbow and wrist of the 
left side were less swollen, and were free from pain in the state of rest, but the 
least motion excited acute pains in them. (Bled a fourth time to twelve ounces ; 
cataplasms, &c. ; blood buffed.) On the fourth day after his admission, and not- 
withstanding his having been bled four times in three days, the elbow, wrist, and 
knee of the left side were swollen and very painful ; the tongue lost its redness ; 



* i. e. Negatively, or by remotion. — Tr. 



DISEASES OF THE CHEST. 



219 



twenty leeches were applied around the knee. On tlie fifth day there was but 
very little pain in the latter, but the right knee then became affected ; state of the 
elbow and wrist of the left side the same ; fever still continued. (Emollients ; 
cataplasms.) On the sixth day the same state. (Another bleeding to twelve 
ounces ; ten leeches around the right knee ; ten more to the left wrist.) In the 
course of the day a visible amendment took place : the différent articulations are 
less swollen, and admit of being moved without much pain ; the patient himself 
states that for the first time he finds himself considerably better. But this was 
not to last long : towards eight o'clock at night ail his joints were almost free 
from pain ; but at ten o'clock he was seized ail at once with a violent pain a little 
above and within the left breast ; this pain continued ail the night, and the next 
morning we found him in the followitig state : — Loud screams in conséquence of 
the very acute pain in the part just mentioned ; this pain was not increased either 
by pressure, by cough, nor by the inspiratory movements, nor even by change of 
position ; consequently it does not possess the characters either of a pleuritic or of 
a muscular pain ; the joints are completely free from pain. Besides, there is no 
cough whatever ; chest sonorous ; respiratory murmur clear, but very strong ; 
beatings of the heart very fréquent, tumultuous, irregular in strength, and inter- 
mittent ; the puise also intermittent, but very small, and compressible. Features 
pale, sharpened, expressive of the most intense anxiety ; extremities cold. This 
alarming aggregate of symptoms was referred to inflammation of the pericardium, 
The patient seemed so weak, that M. Lerminier did not think it expédient to 
bleed him again. (Thirty leeches were applied to the precordial région ; 
sinapisms to the extremities, with the view of bringing back the rheumatic 
affection, which by a species of metastasis seemed to have seized on the 
pericardium.) No amendment took place in the course of the day ; the respira- 
tion, which was tolerably free in the morning, became more and more embarrassed, 
and he died the following night, twenty-nine hours after the commencement of the 
precordial pain. 

The examination of the body confirmed the correctness of the diagnosis. The 
entire internai surface of the pericardium was lined by an exudation which 
was whitish, soft, membraniform, and presenting an areolated appearance. 
Beneath this exudation was observed intense redness of the pericardium. There 
was no fluid effused into its interior ; there was about an ounce of greenish 
sérum obtained from it*. The substance and the différent parts of the heart 
healthy. The pleura merely presented some old cellular adhésions, and the lung 
a sero-sanguinolent engorgement. The stomach was a little red along its great 
curvature. 

Remaries. — We have here one of the most acute cases of pericarditis on record : 
it lasted but twenty-seven hours, and its commencement followed close on the 
disappearance of the articular rheumatism. We shall presently see inflammations 
of the pleura and lung also manifest themselves on the sudden disappearance of 
rheumatic pains of the joints. This is what the ancients called rheumatic metas- 
tasis f . Thèse facts merit ail the attention of the practitioner. We may observe 

* The dulness of sound, which has heen given as one of the characteristic signs of peri- 
carditis, could not then exisfc in this case. 

"f* This metastasis is not always followed hy a pericarditis, pleuritis, or pneumonia. What 
may be remarked in more than one case of this kind, is the lésion of function, which is more 
intense than the lésion of texture seems to he. Thus, after the disappearance of a rheumatic 
pain, we observe palpitations, an acute pain in the precordial région, a pleuritic stitch, greater 
or less dyspnœa. But the readiness with which thèse différent symptoms disappear will not 
allow us to attribute them to a serions altération in the texture of the organ which is the seat 
of them. Still thèse symptoms présent features at least as alarming as those which would 
resuit from hepatisation of the lungs, or from purulent effusion into the pleura or pericardium. 
The same cause which on one and the same day will produce pain in ten différent joints, 
which will be seen to return to the healthy state as rapidly as they became affected, this same 

Q2 



220 



CLINIQUE MÉDICALE, 



also, ho w ineffectuai the several bleedings in this case were, either to reniove the 
articular rheumatism, or to prevent the periearditis *. Here the sympathetic 
irritation of the central organ of the circulation was the cause of ail the symptoms 
and of death. The periearditis was recognised by the nature of the local 
symptoms — to wit, the pain in the precordial région, the tumultuous and irregular 
beatings of the heart, the great frequency, the irregularity, and extrême small- 
ness of the puise. This particular state of the heart and puise has been set 
down by authors as characterising periearditis. However, the following case will 
show us an affection of the pericardium nearly identical, with a very différent 
state of the beatings of the heart, and especially of the puise. 

Case 2. — Pain at the loiuer part of the sternum, and in the région of the heart, 
becoming intense by degrees, succeeding articular pains — Pzdsatio?is of the heart 
obscure; pidse strong and regidar — False membranes in the pericardium* 

A negro, nineteen years old, a tailor, of rather a weak constitution, but in the 
habituai enjoyment of good health, felt, since the 19th of April, pains which 
moved alternately from one joint to another, but which were principally seated in 
the wrist of the right hand, the two knees, and the tibio-tarsal articulation of the 
left side. Having entered the La Charité on the evening of the 23rd April, 1822, 
he was, on the 24th, in the following state : — 

Intense anxiety ; eyes heavy ; the right wrist and knee of the same side slightly 
swollen ; the slightest motion of thèse parts caused the most excruciating pain ; 
the left knee and the parts around the ankles were also painful, but not swollen ; 
puise fréquent and full ; skin hot, and a little moist ; tongue white ; thirst 
moderate ; constipation. (Venesection to the amount of four palettes, &c.) A 
copious sweat took place in the evening. 

On the 25th, the patient was nearly in the same state. The blood drawn on 
the preceding day presented a broad coagulum, of but little consistence, and not 
buffed. The continuance of the pains, and the intensity of the gênerai reaction, 
induced M. Lerminier to prescribe a second bleeding to the amount of three 
palettes. A little time after it was drawn, the blood presented a dense small 
coagulum with elevated edges, covered with a thick buff, and surrounded by a 
copious greenish sérum. Thus there was a perceptible différence between the 
blood drawn the flrst and second time, though in both cases the rein had' been 
opened in the same way. 

The patient took, in the evening, twelve grains of Dover's powder in two 
doses. He perspired very much a great part of the night. 

The next day the joints were no longer swollen, they were scarcely painful ; 
but the patient complained, for the first time, of wandering pains in the thoracic 
parietes ; the respiration was hurried ; the fever still continued. He was bled a 
third time ; the blood presented the same characters as that drawn the second 
time. 

Ail the day the patient complained very much ; the thoracic pains were now 
concentrated in the epigastrium and lower part of the sternum. In the night 
great restlessness, total want of sleep ; no perspiration. 

On the 27th, ail the symptoms were exasperated, The inspiratory movements, 
short and fréquent, were performed at once by the élévation of the ribs and the 
dépression of the diaphragm. The patient uttered constant complaints ; he said 

cause, I say, inay then, \vhen it directs its influence tocards some internai part, produce there 
either a simple modification of action, or a lésion of structure. This second lésion is hut con- 
sécutive to the first, and rarer than it. 

* We shall find in this work fréquent instances of inflammations, -which being attacked 
from their commencement, or during their course, by copious bleedings, still continue their 
course, -whether they are to terminate in health or death. There are, I think, but very few 
cases in which a disease can be thus removed ail at once by a bleeding. 



DTSEASES OF THE CHEST. 



221 



that he fek an acute pain in the epigastrium, which the least pressure inereased, 
and which extended to the lower part of the sternum, and to the precordial 
région. The pains of the limbs eutirely disappeared. Still the patient had no 
cough ; the chest, when struck, sounded well everywhere ; everywhere also the 
respiration was sirong, but clear ; puise very fréquent, regular, and remarkably 
hard, whilst the beating of the heart was heard everywhere with the stéthoscope 
but very feebly ; the ear applied immediately over the regjon of the heart dis- 
tinguished raerely a confused murmur, which did not allow one to recognise the 
pulsations of either the ventricles or the auricles. This group of symptoms, and 
at the same time the absence of every sign of an inflammation of the pleurai, or 
of the lungs, inclined us to suspect the existence of a pericarditis. Forty leeches 
were applied to the precordial région, and a few hours after the epigastrium was 
covered with a blister. 

The patient found himself considerably relieved in the course of the day ; but 
in the evening there was a return of the symptoms, great fever, considérable 
dyspnœa, a threatening of suffocation. He was instantly bled to a large amount ; 
the blood hardly began to flow, when the respiration became freer ; the same 
appearance of the blood as in the two previous bleedings. 

On the morning of the 28th, the state of the patient was very much improved ; 
the respiration was more calm ; the puise less fréquent, and of almost the natural 
strength ; the pain of the epigastrium and of the precordial région was gone. 

On the 29th, the respiration again became very much embarrassed ; puise 
recovered its great frequency and hardness ; a sort of a tumultuous, indefinable 
murmur was heard in the région of the heart. By means of percussion a duller 
sound was heard here than on the preceding days ; the pain of the epigastrium 
and of the precordial région reappeared. The several bleedings having produced 
each time a visible amélioration, recourse was had to them again. (Three palettes 
of blood were again taken ; twelve leeches applied to the région of the heart.) 
The blister to the epigastrium, which was now dry, was replaced by two blisters 
to the legs. 

On the 30th, the respiration, which was still accelerated, was less difficult than 
on the preceding day. The patient no longer felt any pain ; bis countenance 
was considerably calmer and more natural ; puise retaiued its strength ; the blood 
presented an appearance similar to that on the former occasions. (Fifteen leeches 
to the région of the heart.) 

The same state continued during the day. At eight o'clock at night the 
patient was calm ; his countenance not altered ; his respiration appeared tolerably 
free ; he spoke with ease, sat up without much difficulty, and suffered no pain. 
He died suddenly at eleven o'clock at night. 

The body was examined nine hours after death. 

Neither the brain nor its membranes presented any appréciable lésion. Each 
of the latéral ventricles contained two or three small spoonsful of limpid sérum. 

The lungs were healthy ; the cavity of the pericardium contained somewhat 
more than half a litre of turbid sérum ; the portions of serous membrane covering 
the heart, and that lining the fibrous fold, were covered through their 
entire extent by a false membrane, which being marked with nurnerous asperities, 
presented an appearance somewhat similar to that of the second stomach of 
ruminant animais, known by the name of paunck [panse). 

This speciss of mamillated false membrane was already noticed by Corvisart 
and Laennec, as aparticular form of pseudo-membrane, which thèse great observers 
never met but in the pericardium. Along the furrow which marks the place of 
union of the two ventricles, as also at the apex of the heart. albuminous, mem= 
braniform concrétions existed, such as those usually found in inflamed serous 
membranes. In two or three points we found extended. from one of the surfaces 
of the serous membrane to the other, long whhish bands, very soft, and which 



2-22 



CLINIQUE MÉDICALE. 



were torn by the slightest force. The tissue of the heart was very pale; its 
eavities contained fibrinous cîots partly deprived of colouring matter, which 
extended înto the vessels. 

Remarks.— -Here again, as in the preceding case, the inflammation of the peri- 
cardium appeared to arise at the same time that the rheumatic affection of the 
limbs disappeared. The pain, which marked the attack of pericarditis, was at 
first wandering, and not considérable ; perhaps too, at its outset, it was not occa- 
sioned by the disease* of the pericardium. The rheumatism commenced in some 
degree by attacking the thoracic parietes, where wandering pains indicated its 
présence ; then thèse pains became more acute, and occupied successively the 
epigastrium, base of the sternum, and the precordial région ; though very acute, 
they never were so severe as in the patient who forms the subject of the pre- 
ceding case. In that person they ceased only with life ; in the negro, on the 
contrary, they were not continued, and that was another feature of resemblance 
with the rheumatic affection. Several times during the course of the disease we 
observed the dyspnœa and gênerai anxiety to disappear with the pain. What 
w r as very extraordinary, death did not supervene in the midst of an increase of 
the pain, or during an attack of dyspnœa ; it occurred when there was now a 
visible improvement, and when the disease seemed beginning to progress towards 
a resolution. The puise, différent from that presented by the patient in the first 
case, was constantly full, hard, and regular : the pulsations of the heart were at 
the same time very obscure. This is just the reverse of what is observed in other 
eircumstances, where the lésion of the pericardium is however still the same : but 
the heart is otherwise irritated, and the nervous System otherwise influenced. 

Case 3. — Pain in the région of the heart, radiating at intervais to the left arm — 
Beatings ofthe heart very strong at the outset, but subsequently very obscure; puise 
ail through very small and regular — Sound dull in the precordial région — Great 
dyspnœa — Effusion ofblood into the pericardium. 

A shoemaker, thirty-one years" of âge, was admitted into the La Charité, the 
6th of November, 1821. On the 4th of the same month, he had been seized 
with a shivering and gênerai illness ; on the night of the 4th, he had, he said, 
considérable fever. On the rnorning of the 5th, he felt an acute pain on the level 
of, and anterior to, the left breast This continued on the 6th. On the 7th, he 
presented the following state : — Countenance pale, and expressive of suffering and 
anxiety ; risus sardonicus from time to time, a convulsive trembling of the lips. 
The pain of the precordial région was not ver}' intense ; but it increased from 
time to time, became much more severe, and then was not confined to the région 
of the heart ; it spread over ail the left side of the thorax ; at the same time, ail 
the upper extremity of this same side became the seat of well-marked numbness, 
which was sometimes succeeded by an acute pain, which lasted only for some 
moments, and which was seated principally in the anterior surface of the arm and 
fore-arm. Every time the pain thus became more acute the respiration became 
at once very difficult ; the pulsations of the heart became very tumultuous and 
extremety irregular ; the puise was no longer perceptible ; an icy coldness spread 
over the extremities. On the pain again diminishing, the respiration presented 
merely a slight difficulty, the pulsations of the heart retained their strength ; they 
were heard over the entire extent of the anterior part of the thorax ; but they 
recovered some regularity, and the puise rose a little, though it always continued 
very small compared with the strength of the heart's pulsations. The patient 
coughed a little ; the ehest, however, was everywhere sonorous, and the respi- 
ratory murmur was heard everywhere with strength and clearness. This 
aggregate of symptoms presented several traits of resemblance to those which 
bave been considered as belonging to angina pectoris. They were referred to 



DISEASES OF THE CHEST. 



223 



an inflammation of the pericardium. (Venesection to sixteen ounces ; thirty 
leeehes to the precordial région ; sinapisms around the knees.) 

After the bleeding and the application of the leeehes, the paroxyms of pain 
became less severe and less fréquent ; the night was passed better than those 
preceding it. 

On the morning of the 8th, the patient complained of a feeling of tightness 
ratheT than a real pain in the région of the heart. The pulsations of the heart 
not so strong, the puise always very small and of great frequency. The breathing 
was but little embarrassed. In the course of the day the pain of the heart again 
reappeared with violence three or four times, and each time it extended to ail the 
left side of the thorax, with marked numbness of the arm, fore-arm, and hand of 
this side. In the night, he was bled to twelve ounces. On the right bis state 
nearly the same. 

On the lOth November, the sixth day of the disease, new symptoms appeared : 
the pain no longer existed ; the countenance recovered a more natural appear- 
ance ; the pulsations of the heart were less strong and less extended ; the puise 
still very small. Some hours after the visit, without any reappearance of the 
pain, the patient was seized ail at once with great dyspnœa, which went on 
increasing till the following morning. Then, on examining the région of the 
heart with the stéthoscope, we were not a little astonished at no longer hearing 
its pulsations, which were till then so strong, except in a very obscure manner ; 
the puise was smaller than ever ; the chest was percussed again, and for the fîrst 
time we discovered on the left side the existence of a very dull sound from above 
downwards, from the level of the fourth rib to that of the ninth or tenth, and 
transversely from the breast nearly to ail the left half of the sternum inclusive. 
Lying down in the horizontal position was now become impossible ; the patient being 
placed sitting up, could scarcely pronounce a few words with a panting breath ; 
he said he felt as if an iron chain was violently compressing his chest, and choking 
him. (Two blisters to the thighs.) In the course of the day, the oppression 
became more and more considérable, and the patient died in the night. 

Post mortem. The parietes of the thorax were scarcely raised, when we saw to 
project before the heart and lungs an enormous sac which compressed the latter, 
and which proved to be the pericardium distended by nearly a litre of a brownish 
red liquid, similar to blood flowing from a vein. The inner surface of the peri- 
cardium was also lined wkh membranous concrétions of a red colour ; lungs very 
much engorged with blood, as was also the liver ; well-marked venous injection 
of the intestinal canal, visible serous infiltration of the subarachnoid cellular tissue 
of the convexity of the cérébral hémisphères ; white substance of the brain pre- 
sented a considérable number of red points. 

Remarks. — This case présents other symptoms différent from the two cases pre- 
ceding it. Thèse symptoms may be divided into two séries, with respect to the 
organic change which seems to have given rise to them. In the first séries we 
shall arrange those presented by the patient from the commencement of the 
pericarditis up to the ninth day. Thèse symptoms dépend on a lésion of the 
pericardium, similar to that which existed in the two preceding cases ; and still 
thèse symptoms were no longer those merely noticed in cases 1 and 2. Here again, 
indeed, w r e find anomalies both in the beating of the heart and in the puise ; but 
thèse anomalies are not precisely the same : the puise, for instance, is small, as in 
the first case, and regular, as in the second. Wefind that there is pain ; but this 
pain has very remarkable characters ; it becomes acute only at intervais ; being 
almost entirely intermittent, and radiating far from the place of its origin, it might 
be taken for the conséquence of a neurosis*. 

* Thèse same symptoms are produced, in fact, in several cases, in which they can be 
referred only to an affection purely nervous. We have seen at the La Charité a young 
•\voman who, from time to time, felt an acnte pain in the région of the heart ; from this 



224 



CLINIQUE MEDICALE. 



On the ninth day and the beginning of the tenth, a perceptible amendment took 
place ; but alî at once a new disease recommences, or rather the pericarditis, which 
seemed progressing towards a résolution, assumes a new character ; then it is no 
longer a small quantity of purulent matter, of coagulable lymph, which, underthe 
influence of the inflammatory process, is secreted by the pericardium ; it becomes 
the seat of an abundant and sudden hemorrhage ; in a few hours its cavity is filled 
and distended vrith an enormous quantity of blood ; from thenceforth there is eon- 
stantly increasing difnculty in the motions of the heart, and compression of the 
lungs ; death by asphyxia. How différent the symptoms would have been, if 
the effusion had taken place gradually, of which we shall presently see some 
instances. 

Case 4. — Symptoms of pericarditis — Cure. 
A stone-cutter, 39 years of âge, was iîl for ten day s, when he entered the hospiial 
the beginning of May 1823. He had fîrst some signs of cérébral congestion, then 
there was some fever, and for the last four days he complained of an acute pain 
belowthe xiphoid cartilage. He was bled on the day of his admission. The headach 
and dizziness diminished after the bleeding ; but the pain in the epigastrium 
became more acute, and extended to the space between the breast and sternum. 
The application of twenty-four leeches to the epigastrium gave no relief, and on 
the 9th of May, the symptoms were very serions ; he complained of intolérable 
pain in the precordial région ; that of the epigastrium was considerably diminished ; 
the latter was not increased either by pressure or by inspiration ; the patient thought 
it less when he lay on the back, than on either side ; the beatings of the heart, 
which were calm and regular the day before, were now become irregular and 
tumultuous ; the puise was also very irregular, fréquent, and of ordinary strength. 
No symptom indicated any affection of the lung or the pleurae; whence we were 
induced to suspect a pericarditis : this was met by another bleeding of twelve 
ounces, and the application of forty leeches to the precordial région. The next 
day the alarming symptoms partly disappeared : the patient complained merely of 
slight pain in the région of the heart ; the beatings of the heart, as well as the 
puise, had lost their great irregularity ; still there was some fever, and the breath- 
ing was not yet free. It was évident that the inflammation of the pericardium had 
been arrested in its progress, but it still continued. To adopt an expectant treat- 
ment was to run the risk of seeing the inflammation, which was only stopped, 
become again lighted up, and proceed with new activity, or else, a thing not less 
dangerous, pass into the chronic state. Thoroughly convinced that there was in 
this case only an amendment of the symptoms, and that the disease was only sus- 
pended, but not entirely removed, as was proved by the symptoms which still 
remained, M. Lerminier recommenced the same line of treatment which on the 
preceding day appeared so efficacious ; the same quantity of blood was taken ; 
the same number of leeches were applied, and a large blister was placed on the 
interior of each thigh. în the twenty-four hours following, the patient became 
better and better, and on the 12th of May, he was completely convalescent, and 
soon left the hospital perfectly restored. 

région the pain radiated to différent points of the thorax, and clown tliearms. The latter were 
often affected with a numbness, which sometimes proceeded as far as complète paralysis : the 
patient felt at intervais violent palpitations, during which the puise became thready. Thèse 
différent symptoms, however, disappeared after having lasted from some minutes up to 
twenty-four or thirty hours ; during the intervais between them, nothmg unusual was observed 
in the circulatory apparatus. Thèse symptoms were often succeeded by other nervous pheno- 
mena, such as convulsive movements, partial or gênerai, alternations of exaltation and abolition 
of sensibility, symptoms of chorea. In the midst of thèse différent functional disturbances, 
why not i~ecognise one and the same disease, the symptoms of which may vary with the seat, 
but the nature of which remains identical ? I would have no hésitation in saying that this 
woman had from time to time chorea of the heart.. 



DISEASES OF THE CHEST. 



225 



Remaries. — Though it is not quite certain, yet it is very probable, that this was 
a case of pericarditis checked by a very active antiphlogistic treatment. The 
bleedings resorted to the day following the improvement of the lOth of May, were 
perhaps as useful as those employed on the 9th ; they cornpleted thegood effects 
of the former. Too often an acute inflammation terminâtes unfavourably, less 
because it was not combated when its symptoms were very évident, than because 
it is too soon considered to be altogether removed. Persons have no notion that 
the morbid process, which is going on in an inflamed organ, still oftentimes con- 
tinues after its most prominent symptoms have disappeared ; it is then, however, 
that the physician should redouble his attention, and that his task becomes more 
difficult : he should then interrogate every the least symptom, and not give over 
combating the enemy as long as he gives the slightest indication of his présence. 
How many inflammations thus lying dormant for some days, and considered as 
terminated, have ail at once awakened and ended in death ? How many states 
called states of convalescence are but the passage from the acute to the chronic 
stage of the inflammation ? 

The commencement of the disease is also deserving of attention. This is one 
of those cases so frequently occurring in the practice of medicine, where several 
organs appear to be simultaneously or by turns the seat of sanguineous congestions, 
without any of them appearing to be actually inflamed *. Oftentimes the indi- 
vidual returns to health, after congestions of this description have thus traversed 
most of the organs, without the affection of any of them having been prédominant ; 
this is what several authors have called gênerai illness {maladie générale), a very 
vague term signifying nothing else, when applied to the solids, than the simul- 
taneous affection of several tissues, organs, or sets of organs. At other times it 
happens that after the disease has been thus gênerai f , in the sensé just now 
explained, the affection of some one organ becomes prédominant ; this was the 
second stage observed in our patient. 

In the several cases now cited the pericarditis was announced by a group of 
symptoms which rendered its diagnosis sufficiently easy ; we shall now give some 
cases in which the most prominent of thèse symptoms, the pain, no longer existing, 
it is, in some measure, only negatively or by the process of remotion, that we can 
recognise the inflammation of the pericardium. 



ARTICLE II. 

CASES OF ACUTE PERICARDITIS WITHOUT PAIN, BUT WITII DYSPNŒA 

Case 5. — Pulmonary tubercles — Brealhing very little embarrassed — AU at once 
great dyspnœa — Sudden death — Purulent effusion into the pericardium. 
A shoemaker, 28 years of âge, troubled with a cough for the last 22 months, 
and having expectorated a considérable quantity for the first time, fifteen days 
before entering the hospital, presented ail the symptoms of pulmonary phthisis 

* I have endeavoured to show in another work {Précis d 1 Anatomie Pathologique) thatit 
is impossible to draw a well-marked line of démarcation between sanguineous congestion, or 
hyperemia, and what is called inflammation. 

f In the présent state of science we have still, however, need of this term to aîd us in Con- 
necting with their true cause those common morbid states in which there occur, sinmltaneously 
or successively, agréât number of disturbances, organic or functional, the common tie of which 
seetns to be a lésion of the innervation or of haematosis. In such cases there is, no doubt, a 
starting point, but how are we to assign the limits of the disease ? Does it not exist in every 
part where there are blood and nerves ? 



226 



CLINIQUE MEDICALE. 



now in an advanced stage, when \?e saw him the beginning of June 1824. 
Breathing quite free. Heart when examinée! presented nothing remarkable ; some 
gargouillement was heard at the summit of both lungs ; appetite good ; stools 
regular. No new symptom up to the 17th of June, except a little diarrhœa, and 
greaf loss of appetite. On the 17th of June, the patient had a greater appearance 
of suffering than usual ; his features wére very much altered ; he complained for 
the first time of his breathing being embarrassed ; in fact lie spoke with a sort of 
panting voice, and the respiratory movements were perceptibly hurried ; puise 
was small and very fréquent. On the 18th, his state was the same. Did not thèse 
new symptoms dépend on the présence of a pneumonia, which, in conséquence 
either of its seat, or the preceding state of the lungs, escaped détection by the 
stéthoscope ? (Bleeding to eight ounces.) The blood drawn from the vein 
presented a thin, greenish coat. On the 19th and 20th, the oppression became 
still greater -, M. Lerminier compared the state of the patient to that presented 
by phthisical patients, who labour at the same time under organic disease of the 
heart. Face somewhat swollen, eye-lids a little infiltrated, lips swelled and of a 
purple colour. Puise very fréquent, and somewhat irregular in the strength of its 
beats ; from time to time, nearly every fifteen pulsations, it presented a well- 
marked intermission. The heart was heard without any impulsion and to rather a 
small extent. The extrême frequency of its pulsations prevented them from being 
severally distinguished ; they presented also the same intermissions as those of the 
artery. (Blisters to the legs.) On the 21st, the irregularity and intermission of 
the puise still more marked. On the 22nd, orthopnœa ; commencement of the 
trachéal râle. He died in the evening. 

Post mortem. Tubercular excavations in the upper lobe of the two lungs ; 
miliary tubercles in the other lobes. From the symptoms it was probable that 
we should fînd some disease of the heart. The substance of this organ presented 
merely slight hypertrophy of the left ventricle ; but in the pericardium there was 
found a sero-purulent effusion, with membranous concrétions on its parietes. 
There was besides considérable injection of the mucous membrane of the stomach, 
and some redness, without ulcération, in the large intestine, which was very 
contracted. 

Remaries. — Here was a case of pericarditis very différent from the preceding in 
several respects. First the outset w r as marked by symptoms much less serious ; 
nothing was observed but an unusual embarrassaient in the breathing. There was 
throughout total absence of pain. However, on some days ail the symptoms 
which indicate aneurism of the heart manifested themselves : but this aneurism 
could not hâve formed ail at once ; how then should it have given no sign of its 
existence from the time of the patient's admission up to the 17th of June ? Up to 
this day the puise in particular was very regular. The autopsy showed that the 
symptoms observed from the 17th of June, did not dépend on aneurism, but on 
pericarditis. This fact proves then that there are certain forms of inflammation 
of the pericardium, which influence the motions of the heart so as to give rise to 
a disturbance of the circulation, which produces the same phenomena as those 
observed at a certain period of aneurism of the heart. 

Case 6. — Slight asthma for several years — AU at once extrême dyspnœa, the constant 
increase of which causes death by asphyxia — Serons effusion into the pericardium. 
A tailor, twenty years of âge, habitually enjoyed good health, for he did not 
consider as a morbid state, the slight difnculty of breathing which he felt for 
several years back whenever he ascended a height or ran. He had lately spent 
several nights at work. For some days he had cough, w r hen on the 2nd of Mardi 
1820, without any known cause, he was seized ail at once with great dyspnœa, 
the same night lie was bled. The Srd and 4th there was an increase of the 
oppression. He entered the La Charité on the evening of the 5th, and was bled 



DISEASES OF THE OUEST. 



227 



again ; on the 6th, face puffed and livid ; lips violet ; lies on his back with the 
neck tense, and the head retroverted. Sixty-five inspirations per minute ; they 
are performed at once by the élévation of the ribs and dépression of the diaphragm. 
The respiratory murmur was heard everywhere with strength and distinctness, 
except towards the inferior angle of the scapula of the right side, where a little 
mucous râle was heard, owingto the bronchitis which existed for some days back. 
The chest, when percussed, sounded well everywhere, except at the région of the 
heart, where the sound was dull. No thoracic pain either had been or was at 
présent felt by the patient ; his expectoration was purely eatarrhal. The beats 
of the heart, which were regular, were heard with a slight impulsion in the pre- 
cordial région : the hand, when applied over this région, recognised merely a sort 
of vague murmur (bruissement), w r here percussion detected the dull sound. The 
puise was regular, but hard and vibrating, and its frequency was proportioned to 
that of the inspirations : the skin was hot and dry. 

What was the cause of the asphyxia in the case of this patient ? It seemed 
neither to réside in the pleuree, nor in the pulmonary parenchyma, nor in the 
bronchi. By thus reasoning we came to suspect the existence of an affection of 
the pericardium. The dull sound at the région of the heart, the bruissement 
found on the application of the hand over this région, indicated even an effusion 
into this membranous sac. (À third bleeding, thirty leeches to the epigastrium ; 
in the night sinapisms to the legs.) In the evening the patient had a gênerai and 
a very copious perspiration ; but it gave no relief. On the morning of the 7th, 
suffocation still more and more imminent, continuance of the hardness of the puise. 
(Blisters to the thighs ; purgative lavement.) He died in the night, five days after 
the commencement of the dyspnœa. 

Post mortemfourteen hours after death. The pericardium, when viewed externally, 
presented considérable distension ; it contained nearly a litre of limpid colourless 
sérum, in the midst of which small albuminous flocculi floated. The inner surface 
of the pericardium presented no inflammatory appearance. The parietes of the 
left ventricle of the heart were but slightly hypertrophied. The bronchi in gênerai 
were red, the pulmonary parenchyma infarcted, the liver engorged with blood, and 
the digestive canal injected. 

Remarks. — With respect to the great quantity of liquid effused into the pericar- 
dium, this case bears some resemblance to Case 3 ; but in the latter the effusion 
was formed by blood ; in the présent case it consisted of nearly pure sérum, which 
seemed rather the resuit of simple active exhalation, than of inflammation properly 
so called. But who can assign the précise limits which strictly separate thèse tvvo 
affections, which in several cases at least appear but différent forms of one and the 
same primary phenomenon ? Be that as it may, the existence of this effusion was 
indicated by the dull sound and the peculiar bruissement discovered by the hand 
when applied over the région of the heart. Besides, the beats of the heart, as well 
as the puise, preserved great regularity ; the puise continued hard and vibrating. 
Here are phenomena différent f'rom those observed in Case 5 ; and yet in the two 
cases there was one and the same state of hypertrophy of the heart. It might be 
said that here the puise remained under the influence of this hypertrophy, whilst 
in Case 5, it was modifîed by the pericarditis. Here, again, there was total 
absence of pain : is it because there was here but hydro-pericardium ? But in 
Case 5, it was pus that was contained in the envelope of the heart, and the peri- 
carditis was equally free from pain. Before terminating thèse reflections, we 
shall remark, as an accessory circumstance, the slight commencement of asthma 
observed in this individual, and which was attributable to simple hypertrophy of 
the left ventricle of the heart, without any obstacle to the orifices, and without 
any affection in the right side of the heart. 



223 



CLINIQUE MEDICALE. 



Case 1 .—Confluent small pox> — Complication of pericarditis, announced merely by 

great dyspnœa. 

A young man, seventeen years old, entered the La Charité during the year 
1818, on the third day of the éruption of a well-marked small pox. The pustules 
were everywhere very numerous. The symptoms were in other respects very 
mild up to the 7th day, the éruption proceeded very well, no complication inter- 
fering with it ; but at the time the pustules began to be in a perfect state of 
suppuration, the respiration suddenly became embarrassed, without there being 
either cough or bloody expectoration. The two following days the éruption 
became stationary ; several of the pustules became black ; others became filled 
with a reddish sérum ; livid petechise appeared in the intervais between them ; the 
patient fell rapidly into the last degree of prostration, though the tongue continued 
moist and whitish ; the dyspnœa went on increasing, and death took place the 
beginning of the lOth day. 

Post mortem. The only lésions found were a sero-purulent effusion into the 
pericardium, and a considérable injection of the mucous membrane of the 
stomach. 

Remarks. — This case, which is incomplète with respect to the description of 
several symptoms, and in particular those furnished by the heart and puise, is not 
devoid of interest, by reason of the species of complication of which it affords an 
instance. We have here an example of what is called malignant small pox, the 
alarming symptoms and fatal termination of which may be explained by the com- 
plication of an internai inflammation. When this inflammation is a meningitis, a 
pneumonia, a pleuritîs, a gastro-enterite, the diagnosis is always sufficiently easy, 
and the judicious employment of the antiphlogistic treatment then présents many 
chances of success. But here, w r hat symptom could reveal the nature of the 
internai lésion '? The bad aspect which the éruption assumed ail at once, the 
petechiœ which appeared, the sudden prostration of strength, and a remarkable 
dyspnœa, such were the morbid phenomena, the cause of which was to be 
ascertained. With the ancients thèse phenomena would have commenced the 
existence of what they called putrid or malignant small pox. No doubt, in fact, 
but that in conséquence probably of the disturbance occasioned to the nervous 
System by the affection of the skin, there are observed during the course of certain 
cases of small pox, extraordinary and irregular symptoms, the cause of which 
pathological anatomy does not reveal. This happens not only in small pox but in 
ail the acute cutaneous exanthemata. Soute months since we examined the body of 
a woman, who, at the commencement of an éruption of measles, was seized with a 
slight delirium, and died unexpectedly, without any alarming symptom having 
announced this fatal symptom some hours before death. The examination of the body, 
which was conducted with the utmost care, presented ail the organs in a sound state, 
except the bronchi, which were very much injected (as must take place in ail cases 
of measles). In our patient, as in this woman, there was merely a disturbance, 
or perversion of the functions of the nervous System ; and couki either the 
dyspnœa, or the change in the appearance of the éruption, be referred to the 
morbid modification of the innervation ? That which seemed at least very certain, 
is, that the extrême prostration, into which the patient fell suddenly, succeeded the 
very satisfactory state of the strength too rapidly to be considered as real. Did it 
dépend on any internai inflammation ? We were very much disposed to admit 
it, though we could not point out its seat. The dyspnœa seemed, however, to 
indicate some lésion of the organs of respiration or of circulation. The post 
mortem examination showed the cause of it to réside in an inflammation of the 
pericardium. A very striking example, no doubt, of the obscurity of the diagnosis 



DISEASES OF THE CHEST. 



in this disease, ofthe influence ît may exercise overthe variolic éruption, and lastly 
of the great prostration which it may suddenly produce. 

In the case just now cited, the dyspnœa is the only sign remaining, capable of 
announcing that there is an affection of the thoracic organs ; by proceeding on the 
process of exclusion, as we have already stated, we may again, in this case, go so 
far as to recognise, or at least to suspect, the existence of a pericarditis. But there 
are cases still more obscure, in which there is no longer even a perceptible diffi- 
culty of breathing, and where, though the affection is seated in the thorax, there 
is no symptom-indicating such a seat. We shall cite a case of this kind, observed 
at the La Charité ; we shall then annex another of a simiîar nature, contained in 
the work of M. Rostan, on Softening of the Brain. 



ARTICLE III. 

CASES OF ACUTE PERICARDITIS WITHOUT ANY CHARACTERISTIC SYMPTOM. 

Case 8. — Symptoms ofmeningitis — Acute inflammation of the pericardium, 

A woman, twenty-six years of âge, the mother of two children, and who recentiy 
had had a miscarriage, entered the La Charité in the beginning of the year 1820, 
in such a state of delirium, that no information could be obtained regarding lier 
previous history. This delirium was remarkable for the obstinate silence which 
accompanied it ; when interrogated, she fixed her eyes steadfastly without answer- 
ing ; countenance pale ; her lips, separated from each other, and agitated from 
time to time by a convulsive tremor, allowed us to see the tongue, which was moist 
and white. The puise was fréquent and small, but in other respects regular ; skin 
not very hot. (Leeches behind the ears.) The two following days there was 
fréquent rétroversion of the head, sudden risingcf the trunk at intervaîs, subsultus 
tendinum ; the patient speaks and seems to understand, but what she says is 
incohérent. Countenance still pale ; puise, which is very fréquent, intermits. 
On the 4th day of her admission the delirium was gone : she complained only of 
great debility ; the muscles of the face were agitated by convulsive movements, 
which were nearly constant ; the upper extremities presented from time to time 
a sort of tétanie rigîdity. On the 5th day the delirium returned ; the features 
became immoveable and quite altered ; the upper extremities, when raised, fell 
back by their own weight, as if they were paralysed ; in the course of the day 
the patient fell into a state of coma, and died in the night. 

Post mortem. Slight injection of the mucous membrane of the digestive canal in 
some points. Infarction of the posterior part of the lungs. The pericardium was 
lined interiorly with albuminous concrétions, some of which extended like bands, 
still soft, from one of its surfaces to the other ; some ounces of a greenish flocculent 
sérum were also found effused. 

Remarks. — In this patient, the seat of ail the symptoms resided evidently in the 
nervous centres. But were the latter idiopathically affected ? or were they but 
sympathetically so ? and was not the origin and true cause of the disease in the 
inflammation of the pericardium ? 

The case published by M. Rostan, as well as that now recorded, présents 
certain cérébral symptoms, for the explanation of which no other lésion is found 
than a pericarditis ; notwithstanding the obscurity and unusual form of its symp- 
toms, this inflammation was diagnosed by M. Rostan. Here is a summary of the 
case : A woman, after two days' gênerai illness, fell ail at once into a profound 
loss of consciousness. 



230 



CLINIQUE MÉDICALE, 



The next day, eyes fixed, eyeîids open, face flushed ; aîmost absoiute immo- 
bîlity of the limbs, whieh ceased, however, when they were pinched. Puise 
searcely perceptible, no more than the beats of the heart. Death on the fourth 
day. Bloody sérum in the pericardium, with false membrane on its surface*. 

The fact contained in the 8th case, and that recorded by M. Rostan, are well 
calculated to prove that, in proportion to individual susceptibilities, there is no 
organ whose lésion may not give rise to nervous symptoms the most varied, so as 
to produce sympathetically the différent morbid states, the seat of which is placed 
in the nervous centres and their appendages. It has been truly stated, that the 
inflamed digestive canal, more frequently than any other organ, reacts upon the 
brain, and gives rise to the symptoms of an arachnitis or an encephaîitis. But it 
is no less true, as M. Boisseau in particular has clearly shown, that inflammations 
of the other organs, by their sympathetic influence on the brain, may also 
occasion the différent groups of symptoms which constitute what is called ataxie 
fever f . 



CHAPTER IL 

OBSERVATIONS ON CHRONIC PERICARDiTIS. 

4. We have seen in the preceding article, how variable, and oftentimes obscure, 
were the symptoms of acute inflammation of the pericardium. Its chronic in- 
flammation présents itself, in certain cases, under such a form, that it gives rise to 
most of the gênerai symptoms which characterise an organic affection of the 
heart, and particularly to dropsy. The following cases will illustrate thèse 
observations : — 

Case 9.— Very thick false membranes around the heart — Symptoms cf aneurism. 
A mason, twenty-five ye